Provider Demographics
NPI:1346647005
Name:MEDOZ PHARMACY OF POLK LLC
Entity Type:Organization
Organization Name:MEDOZ PHARMACY OF POLK LLC
Other - Org Name:F/K/A MEDOZ PHARMACY OF POLK INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MERMELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-267-7782
Mailing Address - Street 1:40230 US HIGHWAY 27 N
Mailing Address - Street 2:SUITE 100-110
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-2636
Mailing Address - Country:US
Mailing Address - Phone:855-633-6948
Mailing Address - Fax:844-329-6348
Practice Address - Street 1:40230 US HIGHWAY 27 N
Practice Address - Street 2:SUITE 100-110
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-2636
Practice Address - Country:US
Practice Address - Phone:855-633-6948
Practice Address - Fax:844-329-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH28722332B00000X, 3336C0003X
FLPS287223336C0004X
3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH28722OtherPHARMACY STATE LICENSE NUMBER
FL014712100Medicaid
FLPH28722OtherPHARMACY STATE LICENSE NUMBER