Provider Demographics
NPI:1326358516
Name:GONCAN INC
Entity Type:Organization
Organization Name:GONCAN INC
Other - Org Name:TRINITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESCRIPTION DEPT.MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GODWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NWAOBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-882-4785
Mailing Address - Street 1:800 VIRGINIA AVE
Mailing Address - Street 2:SUITE #33
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5829
Mailing Address - Country:US
Mailing Address - Phone:772-882-4785
Mailing Address - Fax:772-519-9982
Practice Address - Street 1:800 VIRGINIA AVE
Practice Address - Street 2:SUITE #33
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5829
Practice Address - Country:US
Practice Address - Phone:772-882-4785
Practice Address - Fax:772-519-9982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH249413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003799300Medicaid
5702231OtherNCPDP PROVIDER IDENTIFICATION NUMBER