Provider Demographics
NPI:1225180722
Name:INDIAN RIVER PHARMACY, INC.
Entity Type:Organization
Organization Name:INDIAN RIVER PHARMACY, INC.
Other - Org Name:PERKINS INDIAN RIVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DECRESCENZO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:772-567-2555
Mailing Address - Street 1:3721 10TH CT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6559
Mailing Address - Country:US
Mailing Address - Phone:772-567-2555
Mailing Address - Fax:772-567-0013
Practice Address - Street 1:3721 10TH CT
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6559
Practice Address - Country:US
Practice Address - Phone:772-567-2555
Practice Address - Fax:772-567-0013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH125653336C0003X
FLPH190773336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1039987OtherNCPDP
FL0435990001Medicare NSC