Provider Demographics
NPI:1417040486
Name:POLK CITY PHARMACY INC
Entity Type:Organization
Organization Name:POLK CITY PHARMACY INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FUTCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:863-984-9631
Mailing Address - Street 1:108 N COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33868-9506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 N COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:FL
Practice Address - Zip Code:33868-9506
Practice Address - Country:US
Practice Address - Phone:863-984-3427
Practice Address - Fax:863-984-9631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH21515333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053987OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FLBP9458236OtherDEA #
FL5540930001Medicare NSC