1336326784 NPI number — ONE SOURCE PHARMACY, LLC

Table of content: (NPI 1336326784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336326784 NPI number — ONE SOURCE PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONE SOURCE 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:
Provider Other Organization Name Type Code:
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:
1336326784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6404 OLD WINTER GARDEN RD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-490-8987
Provider Business Mailing Address Fax Number:
877-490-1060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6404 OLD WINTER GARDEN RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-490-8987
Provider Business Practice Location Address Fax Number:
877-490-1060
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VYAS
Authorized Official First Name:
INDRAJIT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ MGR
Authorized Official Telephone Number:
877-490-8987

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH25399 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0002X , with the licence number: PENDING , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 003464100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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