Provider Demographics
NPI:1053331850
Name:ICP HOLDINGS LLC
Entity Type:Organization
Organization Name:ICP HOLDINGS LLC
Other - Org Name:CARROLLWOOD COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GAETANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-815-1610
Mailing Address - Street 1:11775 N. DALE MABRY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3503
Mailing Address - Country:US
Mailing Address - Phone:813-961-8798
Mailing Address - Fax:813-961-9800
Practice Address - Street 1:11775 N. DALE MABRY HIGHWAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-3503
Practice Address - Country:US
Practice Address - Phone:813-961-8798
Practice Address - Fax:813-961-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH95193336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2007986OtherPK
FL101340800Medicaid
2007986OtherPK