Provider Demographics
NPI:1346554433
Name:1ST COMMUNITY PHARMACY LLC
Entity Type:Organization
Organization Name:1ST COMMUNITY PHARMACY LLC
Other - Org Name:1ST COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:
Authorized Official - Last Name:C
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-656-0641
Mailing Address - Street 1:2775 OLD WINTER GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-2995
Mailing Address - Country:US
Mailing Address - Phone:407-656-0641
Mailing Address - Fax:407-656-0643
Practice Address - Street 1:2775 OLD WINTER GARDEN RD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-2995
Practice Address - Country:US
Practice Address - Phone:407-656-0641
Practice Address - Fax:407-656-0643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
FLPH247843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002601000Medicaid
2126064OtherPK