Provider Demographics
NPI:1417247990
Name:M&S PHARMACY LLC
Entity Type:Organization
Organization Name:M&S PHARMACY LLC
Other - Org Name:CHAMPIONS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MAIKEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:813-205-3670
Mailing Address - Street 1:9945 TRINITY BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4552
Mailing Address - Country:US
Mailing Address - Phone:727-372-2200
Mailing Address - Fax:
Practice Address - Street 1:9945 TRINITY BLVD STE 108
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4552
Practice Address - Country:US
Practice Address - Phone:727-372-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH25314302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization