Provider Demographics
NPI:1730432964
Name:UPSTATE PHARMACY IMA
Entity type:Organization
Organization Name:UPSTATE PHARMACY IMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-455-1325
Mailing Address - Street 1:1025 VERDAE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4032
Mailing Address - Country:US
Mailing Address - Phone:864-286-7545
Mailing Address - Fax:864-455-1350
Practice Address - Street 1:1025 VERDAE BLVD STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4032
Practice Address - Country:US
Practice Address - Phone:864-286-7545
Practice Address - Fax:864-455-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC142493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4231015OtherNCPDP PROVIDER IDENTIFICATION NUMBER