Basic Information
Provider Information | |||||||||
NPI: | 1821599937 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FETTER FAMILY HEALTH CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ELIJAH WRIGHT HEALTH CENTER PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1681 OLD HIGHWAY 6 | ||||||||
Address2: |   | ||||||||
City: | CROSS | ||||||||
State: | SC | ||||||||
PostalCode: | 294363602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437532334 | ||||||||
FaxNumber: | 8438532966 | ||||||||
Practice Location | |||||||||
Address1: | 1681 OLD HIGHWAY 6 | ||||||||
Address2: |   | ||||||||
City: | CROSS | ||||||||
State: | SC | ||||||||
PostalCode: | 294363602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437205655 | ||||||||
FaxNumber: | 8438532966 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2018 | ||||||||
LastUpdateDate: | 07/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | ARETHA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8437224112 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X | 17811 | SC | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2175773 | 01 |   | PK | OTHER | 717811 | 05 | SC |   | MEDICAID |