Provider Demographics
NPI:1316030190
Name:LONGS DRUGSTORES OF SC INC
Entity type:Organization
Organization Name:LONGS DRUGSTORES OF SC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEV
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:404-583-6945
Mailing Address - Street 1:PO BOX 602684
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2684
Mailing Address - Country:US
Mailing Address - Phone:803-256-7481
Mailing Address - Fax:803-748-8602
Practice Address - Street 1:2801 MILLWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-1257
Practice Address - Country:US
Practice Address - Phone:803-256-7481
Practice Address - Fax:803-748-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC150583336C0004X
NC118413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC729638Medicaid
2090219OtherPK
0128340001Medicare NSC