Provider Demographics
NPI:1356083075
Name:FLORIDA DEPARTMENT OF VETERANS' AFFAIRS
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF VETERANS' AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR FDVA HOMES
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:TOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-518-3203
Mailing Address - Street 1:13000 SE TRADITION PARKWAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST. LUICE
Mailing Address - State:FL
Mailing Address - Zip Code:34987
Mailing Address - Country:US
Mailing Address - Phone:772-241-6132
Mailing Address - Fax:
Practice Address - Street 1:13000 SE TRADITION PARKWAY
Practice Address - Street 2:
Practice Address - City:PORT ST. LUICE
Practice Address - State:FL
Practice Address - Zip Code:34987
Practice Address - Country:US
Practice Address - Phone:772-241-6132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA DEPARTMENT OF VETERANS' AFFAIRS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy