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General NPI Number Information
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NPI Number | 1861796518
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Entity Type | Organization
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Legal Business Name | WELVISTA
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Dates
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Enumeration Date | 01/10/2011
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Last Update Date | 01/10/2011
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Provider Practice Location Address
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Address Line | 2700 MIDDLEBURG DRIVE SUITE 104
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City | COLUMBIA
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State | SC
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Zip | 29204
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Country | US
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Telephone | 803-933-9183
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Fax |
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Provider Business Mailing Address
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Address Line | 2700 MIDDLEBURG DR
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City | COLUMBIA
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State | SC
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Zip | 29204-2416
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Country | US
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Telephone | 803-933-9183
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. KEN TROGDON
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Credential |
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Telephone | 803-933-9183
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 10219
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License Number State | SC
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