Provider Demographics
NPI:1164408860
Name:DELTONA PHARMACY OF FLORIDA, LLC
Entity Type:Organization
Organization Name:DELTONA PHARMACY OF FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDULFE
Authorized Official - Suffix:
Authorized Official - Credentials:PHRAMD
Authorized Official - Phone:239-317-0771
Mailing Address - Street 1:25987 S TAMIAMI TRL STE 102
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7807
Mailing Address - Country:US
Mailing Address - Phone:239-317-0771
Mailing Address - Fax:239-317-0771
Practice Address - Street 1:25987 S TAMIAMI TRL STE 102
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7807
Practice Address - Country:US
Practice Address - Phone:239-317-0771
Practice Address - Fax:386-574-1489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH24105333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026286200Medicaid