Healthcare Provider Details

I. General information

NPI: 1508903394
Provider Name (Legal Business Name): ROSA CLARK MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 11/03/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MEMORIAL DR
SENECA SC
29672
US

IV. Provider business mailing address

301 MEMORIAL DR
SENECA SC
29672-9491
US

V. Phone/Fax

Practice location:
  • Phone: 864-882-4629
  • Fax: 864-882-4478
Mailing address:
  • Phone: 864-614-5617
  • Fax: 864-882-4478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number3129
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JAMIE SHANNON LEE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 864-614-5617