Provider Demographics
NPI:1922183987
Name:PICKWICK PHARMACY INC
Entity type:Organization
Organization Name:PICKWICK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:864-277-4180
Mailing Address - Street 1:3219 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2145
Mailing Address - Country:US
Mailing Address - Phone:864-277-4180
Mailing Address - Fax:864-277-4181
Practice Address - Street 1:3219 AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-2145
Practice Address - Country:US
Practice Address - Phone:864-277-4180
Practice Address - Fax:864-277-4181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC166133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2087915OtherPK
SC793691Medicaid