Provider Demographics
NPI:1457686602
Name:KRISHNA PHARMACY LLC
Entity Type:Organization
Organization Name:KRISHNA PHARMACY LLC
Other - Org Name:RIVERDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JIGNESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-362-2760
Mailing Address - Street 1:14102 PALM BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-2244
Mailing Address - Country:US
Mailing Address - Phone:239-362-2760
Mailing Address - Fax:239-362-2761
Practice Address - Street 1:14102 PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2244
Practice Address - Country:US
Practice Address - Phone:239-362-2760
Practice Address - Fax:239-362-2761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
FLPH242943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001554700Medicaid
1049786OtherNCPDP PROVIDER IDENTIFICATION NUMBER