Healthcare Provider Details

I. General information

NPI: 1033423348
Provider Name (Legal Business Name): SPECIALTY PHARMACY MYRTLE BEACH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 N KINGS HWY STE C
MYRTLE BEACH SC
29577-2326
US

IV. Provider business mailing address

5900 N KINGS HWY STE C
MYRTLE BEACH SC
29577-2326
US

V. Phone/Fax

Practice location:
  • Phone: 843-712-1703
  • Fax: 843-712-1705
Mailing address:
  • Phone: 843-712-1703
  • Fax: 843-712-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number11125
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier4229781
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: BILLY WEASE
Title or Position: OWNER
Credential:
Phone: 704-913-7450