Provider Demographics
NPI:1073800579
Name:TITUSVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:TITUSVILLE PHARMACY LLC
Other - Org Name:TITUSVILLE DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARVINDBHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-488-6851
Mailing Address - Street 1:2175 CHENEY HWY STE B
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6792
Mailing Address - Country:US
Mailing Address - Phone:321-268-0911
Mailing Address - Fax:321-268-0918
Practice Address - Street 1:2175 CHENEY HWY STE B
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6792
Practice Address - Country:US
Practice Address - Phone:321-268-0911
Practice Address - Fax:321-268-0918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
FLPH255433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004155200Medicaid
2131551OtherPK
FL004155201Medicaid