1013942051 NPI number — GOOT NURSING HOME PHARMACY 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 1013942051 NPI number — GOOT NURSING HOME PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOT NURSING HOME PHARMACY 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:
Provider Other Organization Name Type Code:
6
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:
1013942051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3802 CORPOREX PARK DR
Provider Second Line Business Mailing Address:
STE 150
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33619-1125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-318-6039
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8826 N 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE C-2
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85021-4154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-995-1320
Provider Business Practice Location Address Fax Number:
602-995-0264
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
502-630-7429

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: Y02939 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0315538 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1013942051 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013942051 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1017729270001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6058574 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100512163 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013942051 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 482646 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200833340A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0199796 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013942051 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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