Provider Demographics
NPI:1053918458
Name:JOHNS ISLAND PHARMACY LLC
Entity type:Organization
Organization Name:JOHNS ISLAND PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DAPORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-789-4777
Mailing Address - Street 1:3133 MAYBANK HWY
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-4838
Mailing Address - Country:US
Mailing Address - Phone:843-789-4777
Mailing Address - Fax:843-789-4017
Practice Address - Street 1:3133 MAYBANK HWY
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-4838
Practice Address - Country:US
Practice Address - Phone:843-795-9554
Practice Address - Fax:843-795-2660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7Z1180Medicaid