1669667424 NPI number — EVERWELL SPECIALTY PHARMACY, LLC

Table of content: (NPI 1669667424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669667424 NPI number — EVERWELL SPECIALTY PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERWELL SPECIALTY 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:
PENSACOLA APOTHECARY, 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:
1669667424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6506 N DAVIS HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32504-6957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-473-9190
Provider Business Mailing Address Fax Number:
850-473-9935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6506 N DAVIS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-6957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-473-9190
Provider Business Practice Location Address Fax Number:
850-473-9935
Provider Enumeration Date:
09/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONTI
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
850-712-7659

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH19748 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2007134 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008486400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109510300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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