Provider Demographics
NPI:1154365468
Name:MODIFICARE LLC
Entity type:Organization
Organization Name:MODIFICARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENO
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-763-8588
Mailing Address - Street 1:1023A W DEKALB ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-4162
Mailing Address - Country:US
Mailing Address - Phone:803-424-0064
Mailing Address - Fax:803-425-8173
Practice Address - Street 1:1023A W DEKALB ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-4162
Practice Address - Country:US
Practice Address - Phone:803-424-0064
Practice Address - Fax:803-425-8173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
SC64963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2114Medicaid
2092185OtherPK
SC7Z1235Medicaid
SC764962Medicaid