1346987633 NPI number — MOUNT DORA RX PHARMACY LLC

Table of content: (NPI 1346987633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346987633 NPI number — MOUNT DORA RX PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNT DORA RX PHARMACY 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:
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:
1346987633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2812 W DR. MARTIN LUTHER KING JR. BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
461 PLAZA DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUSTIS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-729-6557
Provider Business Practice Location Address Fax Number:
352-729-2658
Provider Enumeration Date:
05/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
HARDIKKUMAR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
973-362-6086

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116651800 . 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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