Healthcare Provider Details

I. General information

NPI: 1720689276
Provider Name (Legal Business Name): SWEETGRASS PHARMACY CAROLINA PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 PARK AVENUE BLVD
MOUNT PLEASANT SC
29466
US

IV. Provider business mailing address

1952 LONG GROVE DR STE 1
MT PLEASANT SC
29464-7579
US

V. Phone/Fax

Practice location:
  • Phone: 843-654-4013
  • Fax: 843-654-4014
Mailing address:
  • Phone: 843-654-4013
  • Fax: 843-654-4014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. CYNTHIA FELDMAN
Title or Position: OWNER
Credential: PHARMD, MBA
Phone: 843-654-4013