Provider Demographics
NPI:1154588101
Name:PLANTATION PHARMACY AT WAPPOO ROAD INC
Entity type:Organization
Organization Name:PLANTATION PHARMACY AT WAPPOO ROAD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST,AO
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAPORE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-795-9554
Mailing Address - Street 1:531 WAPPOO RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-2223
Mailing Address - Country:US
Mailing Address - Phone:843-556-1994
Mailing Address - Fax:843-556-1991
Practice Address - Street 1:531 WAPPOO RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-2223
Practice Address - Country:US
Practice Address - Phone:843-556-1994
Practice Address - Fax:843-556-1991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
SC105323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121347OtherPK
SC1154588101Medicaid
SC710532Medicaid