Healthcare Provider Details

I. General information

NPI: 1740219732
Provider Name (Legal Business Name): NINETY SIX PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N CAMBRIDGE ST
NINETY SIX SC
29666-1011
US

IV. Provider business mailing address

206 N CAMBRIDGE ST
NINETY SIX SC
29666-1011
US

V. Phone/Fax

Practice location:
  • Phone: 864-543-2852
  • Fax: 864-543-2982
Mailing address:
  • Phone: 864-543-2852
  • Fax: 864-543-2982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3458
License Number StateSC

VIII. Authorized Official

Name: MR. WILLIAM HAMPTON LONG II
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 864-543-2852