=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700426723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWEETGRASS PHARMACY & COMPOUNDING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2020
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1952 LONG GROVE DR STE 1
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29464-7579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-654-4013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1952 LONG GROVE DR STE 1
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29464-7579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-654-4013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST
-----------------------------------------------------
Name | CYNTHIA FELDMAN
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 843-654-4013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------