Provider Demographics
NPI:1528319548
Name:PEACH VALLEY PHARMACY LLC
Entity type:Organization
Organization Name:PEACH VALLEY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-435-4571
Mailing Address - Street 1:PO BOX 72148
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-2148
Mailing Address - Country:US
Mailing Address - Phone:229-435-4571
Mailing Address - Fax:229-878-4926
Practice Address - Street 1:2310 CHESNEE HWY
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-5505
Practice Address - Country:US
Practice Address - Phone:864-577-0087
Practice Address - Fax:864-577-0599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC142093336C0003X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1528319548Medicaid
2137378OtherPK
SC714209Medicaid
0319740019Medicare NSC