1851750178 NPI number — CRAYTON MITCHELL GROUP

Table of content: (NPI 1851750178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851750178 NPI number — CRAYTON MITCHELL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRAYTON MITCHELL GROUP
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:
SPACE COAST COMMUNITY 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:
1851750178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
197 BOUGAINVILLEA DR STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-636-2275
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
197 BOUGAINVILLEA DR STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-636-2275
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
TRACI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
321-636-2275

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PH29873 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X , with the licence number: PH29873 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PH29873 , 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: 2158119 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 115039900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".