NPIMap

Organization Active NPI

Tidewater Pharmacy & Medical Supply LLC

  • Community/Retail Pharmacy
  • Mount Pleasant, SC
National Provider Identifier
1639562945
Registry record updated Jul 9, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
35780 Issued in SC
Legal business name
TIDEWATER PHARMACY & MEDICAL SUPPLY LLC
Practice address
421 Johnnie Dodds Blvd
Ste 100
Mount Pleasant, SC 29464-2689
Phone
(843) 375-6310
Fax
(843) 375-6311
NPI assigned
Mar 11, 2015
Last updated
Jul 9, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2024

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

Authorized official

Name
Cheryl Lynch
Title
Pic / Manager
Phone
(843) 375-6310

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X 35780 SC Primary

Addresses

Primary practice location

421 Johnnie Dodds Blvd
Ste 100
Mount Pleasant, SC 29464-2689

Mailing address

421 Johnnie Dodds Blvd
Ste 100
Mount Pleasant, SC 29464-2689
Phone (843) 375-6310

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210216002628 SC Part B Supplier - Mass Immunization (Roster Biller Only) 2860799087 Practice locations: Mount Pleasant, SC

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 2

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": "1426032000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1720483200000",
    "number": "1639562945",
    "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": "294642689",
            "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": "294642689",
            "telephone_number": "843-375-6310",
            "fax_number": "843-375-6311"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHARMACY & MEDICAL SUPPLY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-03-11",
        "last_updated": "2024-07-09",
        "certification_date": "2024-07-09",
        "status": "A",
        "authorized_official_last_name": "LYNCH",
        "authorized_official_first_name": "CHERYL",
        "authorized_official_title_or_position": "PIC / MANAGER",
        "authorized_official_telephone_number": "843-375-6310"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "SC",
            "license": "35780",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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 Jul 9, 2024; 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.