1528274222 NPI number — INDIAN RIVER PHARMACY

Table of content: (NPI 1528274222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528274222 NPI number — INDIAN RIVER PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN RIVER 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:
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:
1528274222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3719 10TH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32960-6559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-567-2557
Provider Business Mailing Address Fax Number:
772-567-0013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3719 10TH CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-6559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-567-2557
Provider Business Practice Location Address Fax Number:
772-567-0013
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DECRESCENZO
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
MICHEAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
772-567-2557

Provider Taxonomy Codes

  • Taxonomy code: 3336H0001X , with the licence number:  PH19077 , 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: 1001154 . This is a "NCPDP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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