Provider Demographics
NPI:1417939794
Name:SMA HEALTHCARE INC
Entity Type:Organization
Organization Name:SMA HEALTHCARE INC
Other - Org Name:ACT CORP.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PAHRMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPROUL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH,, CPH
Authorized Official - Phone:386-236-1658
Mailing Address - Street 1:1220 WILLIS AVE
Mailing Address - Street 2:BLDG. 2
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2810
Mailing Address - Country:US
Mailing Address - Phone:386-236-3188
Mailing Address - Fax:386-239-6123
Practice Address - Street 1:1220 WILLIS AVE
Practice Address - Street 2:BLDG. 2
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2810
Practice Address - Country:US
Practice Address - Phone:386-236-3188
Practice Address - Fax:386-239-6123
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMA HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-14
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0010338333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101630000Medicaid
FL00794Medicare ID - Type Unspecified