Provider Demographics
NPI:1215983952
Name:MICA PHARMACY LLC
Entity type:Organization
Organization Name:MICA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BLIZZARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-755-9600
Mailing Address - Street 1:3907 EDMUND HWY
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-1944
Mailing Address - Country:US
Mailing Address - Phone:803-755-9600
Mailing Address - Fax:803-755-3271
Practice Address - Street 1:3907 EDMUND HWY
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-1944
Practice Address - Country:US
Practice Address - Phone:803-755-9600
Practice Address - Fax:803-755-3271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC152163336C0003X
332BP3500X, 335E00000X
SC50002215332BX2000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC790937Medicaid
2146051OtherPK
0135040001Medicare NSC