Provider Demographics
NPI:1326389867
Name:SHIVKRUPA INC
Entity Type:Organization
Organization Name:SHIVKRUPA INC
Other - Org Name:AVON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAULIK
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-453-3884
Mailing Address - Street 1:1577 US HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-2150
Mailing Address - Country:US
Mailing Address - Phone:863-453-3884
Mailing Address - Fax:863-453-3885
Practice Address - Street 1:1577 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-2150
Practice Address - Country:US
Practice Address - Phone:863-453-3884
Practice Address - Fax:863-453-3885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH267193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009303300Medicaid
2139320OtherPK
FL017061900Medicaid