Provider Demographics
NPI:1104913300
Name:MARLBORO DRUG COMPANY
Entity type:Organization
Organization Name:MARLBORO DRUG COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:T
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-479-4248
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-0091
Mailing Address - Country:US
Mailing Address - Phone:843-479-4248
Mailing Address - Fax:843-479-3640
Practice Address - Street 1:113 N MARLBORO ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-3142
Practice Address - Country:US
Practice Address - Phone:843-479-4248
Practice Address - Fax:843-479-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2022-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC500035053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2089193OtherPK
SC618273Medicaid
SC618273Medicaid