Provider Demographics
NPI:1588709828
Name:SUMMERTON DRUGS COMPOUNDING AND DISPENSARY
Entity type:Organization
Organization Name:SUMMERTON DRUGS COMPOUNDING AND DISPENSARY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:803-485-8586
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148-0037
Mailing Address - Country:US
Mailing Address - Phone:803-485-8586
Mailing Address - Fax:803-485-4306
Practice Address - Street 1:115B MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148-6904
Practice Address - Country:US
Practice Address - Phone:803-485-8586
Practice Address - Fax:803-485-4306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
SC91063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093322OtherPK
SC791065Medicaid