NPIMap

Organization Active NPI

Tidewater Pharmacy & Medical Supply LLC

Doing business as Tidewater Pharmacy & Compounding

  • Specialty Pharmacy
  • Mount Pleasant, SC
National Provider Identifier
1417316548
Registry record updated Feb 17, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Specialty PharmacyTaxonomy code 3336S0011X
License
15890 Issued in SC
Legal business name
TIDEWATER PHARMACY & MEDICAL SUPPLY LLC
Doing business as
Tidewater Pharmacy & Compounding
Practice address
421 Johnnie Dodds Blvd
Ste 100
Mount Pleasant, SC 29464-3052
Phone
(843) 375-6310
Fax
(843) 375-6311
NPI assigned
Feb 17, 2016
Last updated
Feb 17, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 17, 2016

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

Authorized official

Name
Chad Louis Straughan, PHARMDNPI 1255749131
Title
Owner/Pharmacist
Phone
(842) 375-6310

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Specialty Pharmacy 3336S0011X 15890 SC Primary

Addresses

Primary practice location

421 Johnnie Dodds Blvd
Ste 100
Mount Pleasant, SC 29464-3052

Mailing address

421 Johnnie Dodds Blvd
Ste 100
Mount Pleasant, SC 29464-3052
Phone (843) 375-6310

Other identifiers 1

IdentifierTypeStateIssuer
715890MedicaidSC

Other names 1

  • Tidewater Pharmacy & Compounding Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Tidewater Pharmacy Compounding5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1455667200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1455667200000",
    "number": "1417316548",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "421 JOHNNIE DODDS BLVD",
            "address_2": "STE 100",
            "city": "MOUNT PLEASANT",
            "state": "SC",
            "postal_code": "294643052",
            "telephone_number": "843-375-6310",
            "fax_number": "843-375-6311"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "421 JOHNNIE DODDS BLVD",
            "address_2": "STE 100",
            "city": "MOUNT PLEASANT",
            "state": "SC",
            "postal_code": "294643052",
            "telephone_number": "843-375-6310",
            "fax_number": "843-375-6311"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHARMACY & MEDICAL SUPPLY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-02-17",
        "last_updated": "2016-02-17",
        "status": "A",
        "authorized_official_last_name": "STRAUGHAN",
        "authorized_official_first_name": "CHAD",
        "authorized_official_middle_name": "LOUIS",
        "authorized_official_title_or_position": "OWNER/PHARMACIST",
        "authorized_official_telephone_number": "842-375-6310",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "3336S0011X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Specialty Pharmacy",
            "state": "SC",
            "license": "15890",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "715890",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tidewater Pharmacy & Compounding",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mount Pleasant, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.