MEDICARE: K-TUCK L L C

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	332B00000X	Durable Medical Equipment & Medical Supplies	50005766	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

General Provider Information

NPI Number	:	1932301959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K-TUCK L L C

Provider Business Mailing Address
First Line	:	PO BOX 1248
Second Line	:
City	:	LAKE VIEW
State	:	SC
Zip	:	29563-1248
Country	:	US
Telephone Number	:	843-759-2800
Fax Number	:	843-759-9974

Provider Business Practice Location Address
First Line	:	303 N MAIN ST
Second Line	:
City	:	LAKE VIEW
State	:	SC
Zip	:	29563
Country	:	US
Telephone Number	:	843-759-2800
Fax Number	:	843-759-9974

Authorized Official
Title or Position	:	PHARMACIST
Name	:	MR. KEITH D TUCKER
Credential	:	RPH
Telephone Number	:	843-759-2800

Provider Enumeration Date	:	06/01/2007
Last Update Date	:	06/17/2008

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