1770580292 NPI number — COMMCARE PHARMACY-WPB LLC

Table of content: (NPI 1770580292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770580292 NPI number — COMMCARE PHARMACY-WPB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMCARE PHARMACY-WPB 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:
COMMCARE SPECIALTY 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:
1770580292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
855 SW 78TH AVE
Provider Second Line Business Mailing Address:
STE C100
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33324-3223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-568-6212
Provider Business Mailing Address Fax Number:
954-568-2765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1689 FORUM PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33401-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-615-0564
Provider Business Practice Location Address Fax Number:
561-615-4508
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BIANCULLI
Authorized Official First Name:
JUDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
954-332-6170

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PH19356 , 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: 2015699 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 026144100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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