Organization
WELVISTA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KEN TROGDON (CHIEF EXECUTIVE OFFICER)
(803) 933-9183
Entity
Organization
Contact information
Practice address
2700 MIDDLEBURG DRIVE, SUITE 104, COLUMBIA, SC 29204
(803) 933-9183
Mailing address
2700 MIDDLEBURG DR, COLUMBIA, SC 29204-2416
(803) 933-9183
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
10219
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4227282
NCPDP
SC
05
—
710219
—
SC
Enumeration date
01/10/2011
Last updated
01/10/2011
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