Healthcare Provider Details

I. General information

NPI: 1912095068
Provider Name (Legal Business Name): PROFESSIONAL PHARMACY OF MARION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/22/2011
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

PO BOX 1109
MARION SC
29571-1109
US

V. Phone/Fax

Practice location:
  • Phone: 843-423-1882
  • Fax: 843-423-5006
Mailing address:
  • Phone: 843-422-1882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2363
License Number StateSC

VIII. Authorized Official

Name: THOMAS FULLER
Title or Position: VP
Credential: BS PHARMACT
Phone: 843-423-1882