Provider Demographics
NPI:1093940496
Name:MEDLINE ENTERPRISES INC
Entity Type:Organization
Organization Name:MEDLINE ENTERPRISES INC
Other - Org Name:PROMED PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:D
Authorized Official - Prefix:
Authorized Official - First Name:KING
Authorized Official - Middle Name:
Authorized Official - Last Name:YEOTAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-494-0458
Mailing Address - Street 1:3336 S DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7840
Mailing Address - Country:US
Mailing Address - Phone:813-832-5151
Mailing Address - Fax:727-489-9489
Practice Address - Street 1:3336 S DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-7840
Practice Address - Country:US
Practice Address - Phone:813-832-5151
Practice Address - Fax:727-489-9489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH23943333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1045702OtherNCPDP PROVIDER IDENTIFICATION NUMBER