1346647005 NPI number — MEDOZ PHARMACY OF POLK LLC

Table of content: (NPI 1346647005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346647005 NPI number — MEDOZ PHARMACY OF POLK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDOZ PHARMACY OF POLK 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:
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:
1346647005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40230 US HIGHWAY 27 N
Provider Second Line Business Mailing Address:
SUITE 100-110
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33837-2636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-633-6948
Provider Business Mailing Address Fax Number:
844-329-6348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40230 US HIGHWAY 27 N
Provider Second Line Business Practice Location Address:
SUITE 100-110
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33837-2636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-633-6948
Provider Business Practice Location Address Fax Number:
844-329-6348
Provider Enumeration Date:
11/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MERMELSTEIN
Authorized Official First Name:
ABRAHAM
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
732-267-7782

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PH28722 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PH28722 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X , with the licence number: PS28722 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PH28722 . This is a "PHARMACY STATE LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 014712100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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