MEDICARE: LORIS DRUG STORE, INC.

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	50001951	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	4214160	OTHER	SC	NCPDP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700881943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LORIS DRUG STORE, INC.

Provider Business Mailing Address
First Line	:	4125 MAIN ST
Second Line	:
City	:	LORIS
State	:	SC
Zip	:	29569-3023
Country	:	US
Telephone Number	:	843-756-4021
Fax Number	:	832-756-9124

Provider Business Practice Location Address
First Line	:	4125 MAIN ST
Second Line	:
City	:	LORIS
State	:	SC
Zip	:	29569-3023
Country	:	US
Telephone Number	:	843-756-4021
Fax Number	:	843-756-9124

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DOUGLAS SINGLETON BAILEY
Credential	:
Telephone Number	:	843-756-4021

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	02/13/2008

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Directions to “LORIS DRUG STORE, INC. ” Practice Location

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