Provider Demographics
NPI:1457656373
Name:MY PHARMACY OF TAMPA LLC
Entity Type:Organization
Organization Name:MY PHARMACY OF TAMPA LLC
Other - Org Name:MY PHARMACY OF TAMPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-692-7584
Mailing Address - Street 1:5002 TARI STREAM WAY
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8416
Mailing Address - Country:US
Mailing Address - Phone:813-689-7580
Mailing Address - Fax:
Practice Address - Street 1:7108 CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-6364
Practice Address - Country:US
Practice Address - Phone:813-628-4441
Practice Address - Fax:813-628-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
FLPH252033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128620OtherPK