Healthcare Provider Details

I. General information

NPI: 1134846322
Provider Name (Legal Business Name): PALMETTO SPECIALTY PHARM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 10/27/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 TWO ISLAND CT UNIT B
MOUNT PLEASANT SC
29466-7418
US

IV. Provider business mailing address

1200 TWO ISLAND CT UNIT B
MOUNT PLEASANT SC
29466-7418
US

V. Phone/Fax

Practice location:
  • Phone: 843-972-7704
  • Fax: 843-972-9395
Mailing address:
  • Phone: 843-972-7704
  • Fax: 843-972-9395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN JOSEPH FENNICK
Title or Position: CEO
Credential: PHARMD
Phone: 843-972-7704