Provider Demographics
NPI:1154590289
Name:AGAPE PHARMACY INC
Entity type:Organization
Organization Name:AGAPE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:803-454-0365
Mailing Address - Street 1:1626 MAIN ST
Mailing Address - Street 2:STE B
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2818
Mailing Address - Country:US
Mailing Address - Phone:803-451-7289
Mailing Address - Fax:803-451-7394
Practice Address - Street 1:1626 MAIN ST STE B
Practice Address - Street 2:STE B
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2818
Practice Address - Country:US
Practice Address - Phone:803-451-7289
Practice Address - Fax:803-451-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC150373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC798421Medicaid
2093484OtherPK