1497713812 NPI number — BELLEVIEW COMMUNITY PHARMACY, LLC

Table of content: (NPI 1497713812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497713812 NPI number — BELLEVIEW COMMUNITY PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLEVIEW COMMUNITY PHARMACY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BELLEVIEW COMMUNITY PHARMACY, INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497713812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10762 SE US HWY 441
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34420-3805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-347-4064
Provider Business Mailing Address Fax Number:
352-347-6832

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 CITRUS BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-3063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-728-0477
Provider Business Practice Location Address Fax Number:
352-315-3836
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRIMI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER/OWNER
Authorized Official Telephone Number:
352-427-8680

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PH21895 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 031408100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 031408101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1094185 . This is a "NCPDP PROVIDER ID #" identifier . This identifiers is of the category "OTHER".




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