Healthcare Provider Details

I. General information

NPI: 1295166742
Provider Name (Legal Business Name): PALMETTO SPECIALTY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 MCSWAIN DR STE C
WEST COLUMBIA SC
29169-4804
US

IV. Provider business mailing address

172 MCSWAIN DR SUITE C
WEST COLUMBIA SC
29169-4804
US

V. Phone/Fax

Practice location:
  • Phone: 803-724-1501
  • Fax: 855-286-1676
Mailing address:
  • Phone: 803-724-1501
  • Fax: 855-286-1676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number14939
License Number StateSC

VIII. Authorized Official

Name: CONNIE HARTLEY
Title or Position: VICE-PRESIDENT
Credential:
Phone: 803-227-5447