Provider Demographics
NPI:1083848865
Name:ANNALICE LLC
Entity Type:Organization
Organization Name:ANNALICE LLC
Other - Org Name:PEGASUS RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:OHIHOIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-534-1318
Mailing Address - Street 1:115 W BELT AVE
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-5101
Mailing Address - Country:US
Mailing Address - Phone:352-793-3100
Mailing Address - Fax:352-793-3106
Practice Address - Street 1:115 W BELT AVE
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-5101
Practice Address - Country:US
Practice Address - Phone:352-793-3100
Practice Address - Fax:352-793-3106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-08
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH240293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120290OtherPK
FL001215500Medicaid