Provider Demographics
NPI:1336680412
Name:COUNTRYSIDE PHARMACY
Entity Type:Organization
Organization Name:COUNTRYSIDE PHARMACY
Other - Org Name:SHIELDS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUSSEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-648-2680
Mailing Address - Street 1:2196 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-5650
Mailing Address - Country:US
Mailing Address - Phone:727-648-2680
Mailing Address - Fax:727-648-2695
Practice Address - Street 1:2196 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-5650
Practice Address - Country:US
Practice Address - Phone:727-648-2680
Practice Address - Fax:727-648-2695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH305003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168277OtherPK