Healthcare Provider Details

I. General information

NPI: 1225287451
Provider Name (Legal Business Name): INDIAN LAND PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8437 CHARLOTTE HWY
INDIAN LAND SC
29707-7587
US

IV. Provider business mailing address

8437 CHARLOTTE HWY
INDIAN LAND SC
29707-7587
US

V. Phone/Fax

Practice location:
  • Phone: 803-578-8800
  • Fax: 803-578-8801
Mailing address:
  • Phone: 803-578-8800
  • Fax: 803-578-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number10186
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: VIPUL PATEL
Title or Position: PIC
Credential: PHARM D.
Phone: 803-578-8801