1417216128 NPI number — PROCARE PHARMACY, LLC

Table of content: (NPI 1417216128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417216128 NPI number — PROCARE PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROCARE 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:
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:
1417216128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1127 BRYN MAWR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92374-4558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-799-4174
Provider Business Mailing Address Fax Number:
909-799-4364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 NORTHEAST EXPY NE
Provider Second Line Business Practice Location Address:
SUITE B-800
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-367-9111
Provider Business Practice Location Address Fax Number:
404-367-9199
Provider Enumeration Date:
05/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MARKOS
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
401-770-3303

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; 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: PHRE009830 , registered in the state of GA ; 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: "Y" .

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

  • Identifier: 003123975A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7G9830 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2135141 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1417216128 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 058513900 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 018254000 . 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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