Provider Demographics
NPI:1336475482
Name:MEDLINE ENTERPRISES INC
Entity Type:Organization
Organization Name:MEDLINE ENTERPRISES INC
Other - Org Name:PASADENA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KING
Authorized Official - Middle Name:
Authorized Official - Last Name:YEOTAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-344-5151
Mailing Address - Street 1:PO BOX 55632
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33732-5632
Mailing Address - Country:US
Mailing Address - Phone:813-494-0458
Mailing Address - Fax:727-489-9489
Practice Address - Street 1:1206 PASADENA AVE S
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-6202
Practice Address - Country:US
Practice Address - Phone:727-344-5151
Practice Address - Fax:727-489-9489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH24282333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1049926OtherNCPDP PROVIDER IDENTIFICATION NUMBER