=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740201706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLTCP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 10/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 ZIMALCREST DR
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29210-6833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-731-0203
-----------------------------------------------------
Fax | 866-935-3629
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4900 PERRY HWY BUILDING 2, 3RD FL
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15229-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-931-3131
-----------------------------------------------------
Fax | 412-931-2361
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | DUANE EVERETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-397-8904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 14061
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------