MEDICARE: SKRIP SHOPPE 2 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy	16455	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2159437	OTHER		PK

General Provider Information

NPI Number	:	1316301393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKRIP SHOPPE 2 LLC

Provider Business Mailing Address
First Line	:	3907 EDMUND HWY STE A
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29170-1944
Country	:	US
Telephone Number	:	803-764-2408
Fax Number	:	803-888-6123

Provider Business Practice Location Address
First Line	:	3907 EDMUND HWY STE A
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29170-1944
Country	:	US
Telephone Number	:	803-764-2408
Fax Number	:	803-888-6123

Authorized Official
Title or Position	:	OWNER
Name	:	JOSEPH BLIZZARD
Credential	:
Telephone Number	:	803-764-2408

Provider Enumeration Date	:	04/06/2016
Last Update Date	:	04/12/2016

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Directions to “SKRIP SHOPPE 2 LLC ” Practice Location

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