Provider Demographics
NPI:1215208616
Name:FLORIDA KERELOS LLC
Entity Type:Organization
Organization Name:FLORIDA KERELOS LLC
Other - Org Name:EMBASSY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:NASHAAT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-842-3400
Mailing Address - Street 1:2690 CRYSTAL CIR
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-2409
Mailing Address - Country:US
Mailing Address - Phone:727-331-9806
Mailing Address - Fax:
Practice Address - Street 1:9320 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-4772
Practice Address - Country:US
Practice Address - Phone:727-842-3400
Practice Address - Fax:727-842-3800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH258863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5708752OtherNCPDP PROVIDER IDENTIFICATION NUMBER