1417902255 NPI number — BELLEVIEW COMMUNITY PHARMACY

Table of content: (NPI 1417902255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417902255 NPI number — BELLEVIEW COMMUNITY PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLEVIEW COMMUNITY PHARMACY
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:
LEESBURG COMMUNITY PHARMACY
Provider Other Organization Name Type Code:
3
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:
1417902255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10762 SE US HIGHWAY 441
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34420-3805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-347-4064
Provider Business Mailing Address Fax Number:
352-347-6832

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 CITRUS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-3063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-728-0477
Provider Business Practice Location Address Fax Number:
352-315-3836
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRIMI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MGR
Authorized Official Telephone Number:
352-347-5225

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH21895 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 116889300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2006622 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 116889300 . 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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