Provider Demographics
NPI:1114343597
Name:MEDLIFE PHARMACY LLC
Entity Type:Organization
Organization Name:MEDLIFE PHARMACY LLC
Other - Org Name:WINTERGARDEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VAMSEE
Authorized Official - Middle Name:CHARAN
Authorized Official - Last Name:NALAGANDLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-656-2604
Mailing Address - Street 1:736 S DILLARD ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3908
Mailing Address - Country:US
Mailing Address - Phone:407-656-2604
Mailing Address - Fax:407-654-1464
Practice Address - Street 1:736 S DILLARD ST UNIT C
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3908
Practice Address - Country:US
Practice Address - Phone:407-656-2604
Practice Address - Fax:407-654-1464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH294303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014189300Medicaid
2154708OtherPK