Healthcare Provider Details

I. General information

NPI: 1922288869
Provider Name (Legal Business Name): PROFESSIONAL PHARMACY OF MARION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N MAIN ST
MARION SC
29571-3025
US

IV. Provider business mailing address

223 N MAIN ST
MARION SC
29571-3025
US

V. Phone/Fax

Practice location:
  • Phone: 843-423-1882
  • Fax: 843-423-5006
Mailing address:
  • Phone: 843-423-1882
  • Fax: 843-423-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberDPE023
License Number StateSC

VIII. Authorized Official

Name: MR. THOMAS E FULLER
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 843-423-1882