1770873135 NPI number — ONE SOURCE PHARMACY OF BRADENTON

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770873135 NPI number — ONE SOURCE PHARMACY OF BRADENTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONE SOURCE PHARMACY OF BRADENTON
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:
1770873135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6404 OLD WINTER GARDEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32835-1348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-490-8987
Provider Business Mailing Address Fax Number:
877-490-8987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3501 CORTEZ RD W
Provider Second Line Business Practice Location Address:
UNIT 901B
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-490-8987
Provider Business Practice Location Address Fax Number:
877-490-8987
Provider Enumeration Date:
04/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VYAS
Authorized Official First Name:
INDRAJIT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MGR
Authorized Official Telephone Number:
877-490-8987

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH25399 , 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)





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