Provider Demographics
NPI: | 1033837307 |
---|---|
Name: | MY PHARMACY CRYSTAL RIVER, LLC |
Entity Type: | Organization |
Organization Name: | MY PHARMACY CRYSTAL RIVER, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VP OF FINANCE & SALES |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BRIAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BRANHAM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 321-221-0658 |
Mailing Address - Street 1: | 2710 REW CIRCLE SUITE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | OCOEE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 34761 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 407-654-5414 |
Mailing Address - Fax: | 407-654-9614 |
Practice Address - Street 1: | 927 N CITRUS AVE |
Practice Address - Street 2: | |
Practice Address - City: | CRYSTAL RIVER |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34428 |
Practice Address - Country: | US |
Practice Address - Phone: | 352-565-7342 |
Practice Address - Fax: | 352-565-5880 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | MY PHARMACY CRYSTAL RIVER, LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2022-08-22 |
Last Update Date: | 2022-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |