1780668087 NPI number — THE APOTHECARY OF GULFPORT

Table of content: (NPI 1780668087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780668087 NPI number — THE APOTHECARY OF GULFPORT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE APOTHECARY OF GULFPORT
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:
1780668087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5802 28TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33707-5227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-321-3000
Provider Business Mailing Address Fax Number:
727-344-5620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5802 28TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33707-5227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-321-3000
Provider Business Practice Location Address Fax Number:
727-344-5620
Provider Enumeration Date:
12/01/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
V
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
727-321-3000

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PS15676 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PH1331 , 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: 105203900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1048861 . This is a "NABP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".