Provider Demographics
NPI:1376072132
Name:SEMINOLE PHARMACY
Entity Type:Organization
Organization Name:SEMINOLE PHARMACY
Other - Org Name:SEMINOLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-965-1331
Mailing Address - Street 1:30290 JOSIE BILLIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-9502
Mailing Address - Country:US
Mailing Address - Phone:863-983-1197
Mailing Address - Fax:863-983-1214
Practice Address - Street 1:31055 JOSIE BILLIE HIGHWAY
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440
Practice Address - Country:US
Practice Address - Phone:863-983-1197
Practice Address - Fax:863-983-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169622OtherPK