Provider Demographics
NPI:1225477862
Name:MALABAR PHARMACY LLC
Entity Type:Organization
Organization Name:MALABAR PHARMACY LLC
Other - Org Name:MALABAR DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANKUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:321-775-0911
Mailing Address - Street 1:930 MALABAR RD SE STE 1
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3252
Mailing Address - Country:US
Mailing Address - Phone:321-775-0911
Mailing Address - Fax:877-232-9689
Practice Address - Street 1:930 MALABAR RD SE STE 1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3252
Practice Address - Country:US
Practice Address - Phone:321-775-0911
Practice Address - Fax:877-232-9689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH24682310400000X, 3104A0625X, 3104A0630X, 315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002740401Medicaid