Provider Demographics
NPI:1194837179
Name:PHARMACY SERVICES DIVIRSIFIED INC
Entity Type:Organization
Organization Name:PHARMACY SERVICES DIVIRSIFIED INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-605-8879
Mailing Address - Street 1:PO BOX 160907
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36616-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 S FLORIDA ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-1955
Practice Address - Country:US
Practice Address - Phone:251-471-4560
Practice Address - Fax:251-471-9445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X, 3336C0004X, 3336M0003X
AL1104033336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0125460OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0125460OtherOTHER ID NUMBER-COMMERCIAL NUMBER
AL00055658Medicare PIN
AL0909210001Medicare NSC