1366416448 NPI number — PACIFICO NATIONAL INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366416448 NPI number — PACIFICO NATIONAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFICO NATIONAL INC
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:
AMEX 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:
1366416448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 ELIZABETH ST
Provider Second Line Business Mailing Address:
STE J
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-872-0723
Provider Business Mailing Address Fax Number:
321-872-0721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 ELIZABETH ST
Provider Second Line Business Practice Location Address:
STE J
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-872-0723
Provider Business Practice Location Address Fax Number:
321-872-0721
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANGREE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
321-872-0723

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  16452MS , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 5301008923 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PH27532 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: FL1446 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: NRX1701137 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: A9-0001042 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 3942 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: P03052 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 64000903A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 22-02899 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PHNR 000556 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 006292 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 054.016601 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PMP-1330 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1366416448 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366416448 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 226807 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 546330 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000055714 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366416448 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366416448 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2856995 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02199910 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 134038 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2013120 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 201352590A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100410000 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026562600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1028490 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105780400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200647710A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366416448 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2059467 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500707688 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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