1700194800 NPI number — D.Y.L. LLC

Table of content: (NPI 1700194800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700194800 NPI number — D.Y.L. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
D.Y.L. 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:
SOUTH LAKE PHARMACY
Provider Other Organization Name Type Code:
3
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:
1700194800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38101 5TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEPHYRHILLS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33542-4973
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-395-5667
Provider Business Mailing Address Fax Number:
813-715-2478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38101 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZEPHYRHILLS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33542-4973
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-395-5667
Provider Business Practice Location Address Fax Number:
813-715-2478
Provider Enumeration Date:
09/22/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MEDRANO
Authorized Official First Name:
HECTOR
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER- MANAGING MEMBER
Authorized Official Telephone Number:
813-395-5667

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PH24899 , 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: 003197900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 022343900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".