Provider Demographics
NPI:1326294919
Name:ST JOSEPH PHARMACY & MEDICAL SUPPLIES LLC
Entity Type:Organization
Organization Name:ST JOSEPH PHARMACY & MEDICAL SUPPLIES LLC
Other - Org Name:ST JOSEPH PHARMACY & MEDICAL SUPPLIES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MINIMOL
Authorized Official - Middle Name:
Authorized Official - Last Name:KURIAKOSE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:813-782-4854
Mailing Address - Street 1:35780 SR 54
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33541-2242
Mailing Address - Country:US
Mailing Address - Phone:813-782-4854
Mailing Address - Fax:813-782-4856
Practice Address - Street 1:35780 STATE ROAD 54 STE 101
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33541-2242
Practice Address - Country:US
Practice Address - Phone:813-782-4854
Practice Address - Fax:813-782-4856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
FLPH242473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001689600Medicaid
2122052OtherPK