Healthcare Provider Details

I. General information

NPI: 1104076694
Provider Name (Legal Business Name): VA CMOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3725 RIVERS AVE STE 2
NORTH CHARLESTON SC
29405-7072
US

IV. Provider business mailing address

3725 RIVERS AVE STE 2
NORTH CHARLESTON SC
29405-7072
US

V. Phone/Fax

Practice location:
  • Phone: 843-745-8649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DENA WOLFORTH
Title or Position: PROGRAM MANAGER
Credential:
Phone: 843-745-8636