MEDICARE: HOPE CLINIC

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	332900000X	Non-Pharmacy Dispensing Site
2	3336C0002X	Clinic Pharmacy

General Provider Information

NPI Number	:	1952699688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOPE CLINIC

Provider Business Mailing Address
First Line	:	110 EXECUTIVE PKWY
Second Line	:
City	:	MONCKS CORNER
State	:	SC
Zip	:	29461-3930
Country	:	US
Telephone Number	:	843-725-1225
Fax Number	:	888-318-5567

Provider Business Practice Location Address
First Line	:	110 EXECUTIVE PKWY
Second Line	:
City	:	MONCKS CORNER
State	:	SC
Zip	:	29461-3930
Country	:	US
Telephone Number	:	843-725-1225
Fax Number	:	888-318-5567

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	TEMISAN ETIKEVENTSE
Credential	:
Telephone Number	:	843-725-1225

Provider Enumeration Date	:	07/15/2011
Last Update Date	:	07/15/2011

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