Provider Demographics
NPI:1346410537
Name:17TH STREET DISCOUNT PHARMACY INC
Entity Type:Organization
Organization Name:17TH STREET DISCOUNT PHARMACY INC
Other - Org Name:17TH STREET DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:352-351-3330
Mailing Address - Street 1:2506 SE 17TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5523
Mailing Address - Country:US
Mailing Address - Phone:352-351-3330
Mailing Address - Fax:352-351-3390
Practice Address - Street 1:2506 SE 17TH ST STE B
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5523
Practice Address - Country:US
Practice Address - Phone:352-351-3330
Practice Address - Fax:352-351-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH196283336C0003X
3336C0004X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2006500OtherPK
FL010426500Medicaid