=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902325715
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORENCE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2017
-----------------------------------------------------
Last Update Date | 09/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1945 W PALMETTO ST UNIT 32
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29501-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-673-9107
-----------------------------------------------------
Fax | 843-673-9107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 KING CHARLES DR
-----------------------------------------------------
City | SEABROOK
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29940-2320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-729-5583
-----------------------------------------------------
Fax | 843-379-3232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEREMY SIMMONS
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 843-729-5583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 17472
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------