NPIMap

Organization Active NPI

Longs Drugstores of SC Inc

Doing business as Avita Pharmacy

  • Community/Retail Pharmacy
  • Rock Hill, SC
National Provider Identifier
1275030645
Registry record updated Jun 27, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
17812 Issued in SC
Legal business name
LONGS DRUGSTORES OF SC INC
Doing business as
Avita Pharmacy
Practice address
455 Lakeshore Pkwy
Rock Hill, SC 29730-4205
Phone
(803) 992-3263
Fax
(844) 641-3263
NPI assigned
Apr 11, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 27, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ashley Ellis
Title
Corporate Counsel/Ao
Phone
(704) 641-7967

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 17812 SC Primary

Addresses

Primary practice location

455 Lakeshore Pkwy
Rock Hill, SC 29730-4205

Mailing address

10604 Coursey Blvd
Baton Rouge, LA 70816
Phone (225) 236-1541

Other identifiers 2

IdentifierTypeStateIssuer
2177212OtherPK
717812MedicaidSC

Other names 1

  • Avita Pharmacy Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040614001381 SC Part B Supplier - Mass Immunization (Roster Biller Only) 6103800768 5 other NPIs on this enrollment
Practice locations: Rock Hill, SC; Greenville, SC; Charleston, SC
O20241126001285 SC Part B Supplier - Pharmacy 6103800768 2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Charleston, SC; Greenville, SC; Rock Hill, SC

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Long's Drugstores of South Carolina Inc4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1523404800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1530057600000",
    "number": "1275030645",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10604 COURSEY BLVD",
            "city": "BATON ROUGE",
            "state": "LA",
            "postal_code": "70816",
            "telephone_number": "225-236-1541",
            "fax_number": "225-663-2158"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "455 LAKESHORE PKWY",
            "city": "ROCK HILL",
            "state": "SC",
            "postal_code": "297304205",
            "telephone_number": "803-992-3263",
            "fax_number": "844-641-3263"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LONGS DRUGSTORES OF SC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-04-11",
        "last_updated": "2018-06-27",
        "status": "A",
        "authorized_official_last_name": "ELLIS",
        "authorized_official_first_name": "ASHLEY",
        "authorized_official_title_or_position": "CORPORATE COUNSEL/AO",
        "authorized_official_telephone_number": "704-641-7967"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "SC",
            "license": "17812",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2177212",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "717812",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Avita Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Avita Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rock Hill, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.