Provider Demographics
NPI:1366531055
Name:IRMO FAMILY PHARMACY LLC
Entity type:Organization
Organization Name:IRMO FAMILY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:D
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-917-3627
Mailing Address - Street 1:7001 ST ANDREWS RD
Mailing Address - Street 2:A-16
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212
Mailing Address - Country:US
Mailing Address - Phone:803-749-9988
Mailing Address - Fax:803-749-9096
Practice Address - Street 1:7001 ST ANDREWS RD
Practice Address - Street 2:A-16
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212
Practice Address - Country:US
Practice Address - Phone:803-749-9988
Practice Address - Fax:803-749-9096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC50007248333600000X
3336C0003X
SC50009341333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4224870OtherOTHER ID NUMBER-COMMERCIAL NUMBER
SC772483Medicaid
4224870OtherNCPDP