Provider Demographics
NPI:1073547287
Name:LIDDY'S PHARMACY, LLC
Entity Type:Organization
Organization Name:LIDDY'S PHARMACY, LLC
Other - Org Name:SYNERGY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-647-9899
Mailing Address - Street 1:4204 S FLORIDA AVE STE E
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1669
Mailing Address - Country:US
Mailing Address - Phone:863-647-9899
Mailing Address - Fax:863-709-0030
Practice Address - Street 1:4204 S FLORIDA AVE STE E
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1669
Practice Address - Country:US
Practice Address - Phone:863-647-9899
Practice Address - Fax:863-709-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH195023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1012171OtherNCPDP