Provider Demographics
NPI:1467752691
Name:BREVARD PHARMACY LLC
Entity Type:Organization
Organization Name:BREVARD PHARMACY LLC
Other - Org Name:PORT ST JOHN DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRIKABEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:407-488-6851
Mailing Address - Street 1:6250 N US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-4926
Mailing Address - Country:US
Mailing Address - Phone:321-305-6975
Mailing Address - Fax:321-305-6978
Practice Address - Street 1:6250 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-4926
Practice Address - Country:US
Practice Address - Phone:321-305-6975
Practice Address - Fax:321-305-6978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
FLPH305093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127271OtherPK
FL003226300Medicaid
FL003226301Medicaid