1154727519 NPI number — FORT PIERCE DISCOUNT 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 1154727519 NPI number — FORT PIERCE DISCOUNT PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT PIERCE DISCOUNT 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:
1154727519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1727 OKEECHOBEE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34950-3945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-577-6469
Provider Business Mailing Address Fax Number:
772-577-6657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1727 OKEECHOBEE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34950-3945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-873-3743
Provider Business Practice Location Address Fax Number:
772-577-6657
Provider Enumeration Date:
11/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SHARMA
Authorized Official First Name:
SONIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
772-577-6469

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH28682 , 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: 2148672 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 014177400 . 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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