Healthcare Provider Details

I. General information

NPI: 1659360873
Provider Name (Legal Business Name): MCLEOD HEALTH CLARENDON LTC PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E HOSPITAL ST STE 1B
MANNING SC
29102-3149
US

IV. Provider business mailing address

50 E HOSPITAL ST STE 1B
MANNING SC
29102-3149
US

V. Phone/Fax

Practice location:
  • Phone: 803-435-5272
  • Fax: 803-435-5271
Mailing address:
  • Phone: 803-435-5272
  • Fax: 803-435-5271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number16726
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL FULTON ERVIN III
Title or Position: SR VP AND CFO
Credential:
Phone: 843-777-2910