Organization
VA CMOP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DENA WOLFORTH (PROGRAM MANAGER)
(843) 745-8636
Entity
Organization
Contact information
Practice address
3725 RIVERS AVE STE 2, NORTH CHARLESTON, SC 29405-7072
(843) 745-8649
Mailing address
3725 RIVERS AVE STE 2, NORTH CHARLESTON, SC 29405-7072
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
—
—
3336M0002X
Mail Order Pharmacy
Primary
—
—
Other
Enumeration date
09/22/2008
Last updated
09/22/2008
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