Provider Demographics
NPI:1225545064
Name:DELTONA MEDICAL ARTS PHARMACY INC
Entity Type:Organization
Organization Name:DELTONA MEDICAL ARTS PHARMACY INC
Other - Org Name:TOWN CENTER PHARMACY - DELTONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-774-7933
Mailing Address - Street 1:1200 DELTONA BLVD
Mailing Address - Street 2:SUITE 50
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-6306
Mailing Address - Country:US
Mailing Address - Phone:386-259-4712
Mailing Address - Fax:386-259-4712
Practice Address - Street 1:1200 DELTONA BLVD
Practice Address - Street 2:SUITE 50
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-6306
Practice Address - Country:US
Practice Address - Phone:386-259-4712
Practice Address - Fax:386-259-4712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X, 3336S0011X
FLPH311053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL711979Medicaid
2177518OtherPK