Provider Demographics
NPI:1336326784
Name:ONE SOURCE PHARMACY, LLC
Entity Type:Organization
Organization Name:ONE SOURCE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MGR
Authorized Official - Prefix:MR
Authorized Official - First Name:INDRAJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:VYAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-490-8987
Mailing Address - Street 1:6404 OLD WINTER GARDEN RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835
Mailing Address - Country:US
Mailing Address - Phone:877-490-8987
Mailing Address - Fax:877-490-1060
Practice Address - Street 1:6404 OLD WINTER GARDEN RD
Practice Address - Street 2:STE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835
Practice Address - Country:US
Practice Address - Phone:877-490-8987
Practice Address - Fax:877-490-1060
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONE SOURCE PHARMACY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH253993336C0003X
FLPENDING3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003464100Medicaid