Provider Demographics
NPI:1164709663
Name:POLYPILL COMPOUND MEDICATIONS LLC
Entity Type:Organization
Organization Name:POLYPILL COMPOUND MEDICATIONS LLC
Other - Org Name:POLYPILL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-920-1155
Mailing Address - Street 1:5701 SW 134TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST RANCHES
Mailing Address - State:FL
Mailing Address - Zip Code:33330-3100
Mailing Address - Country:US
Mailing Address - Phone:407-920-1155
Mailing Address - Fax:407-540-9614
Practice Address - Street 1:4401 SHERIDAN ST STE B
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3513
Practice Address - Country:US
Practice Address - Phone:855-765-9745
Practice Address - Fax:866-355-0176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-11
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH257913336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5709398OtherNCPDP PROVIDER IDENTIFICATION NUMBER