Provider Demographics
NPI:1467830638
Name:MIDWAY SPECIALTY CARE RX LLC
Entity Type:Organization
Organization Name:MIDWAY SPECIALTY CARE RX LLC
Other - Org Name:MIDWAY SPECIALTY CARE CENTER INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:772-465-4442
Mailing Address - Street 1:356 E MIDWAY ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-7148
Mailing Address - Country:US
Mailing Address - Phone:772-464-9746
Mailing Address - Fax:
Practice Address - Street 1:3255 S US HIGHWAY I
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-6381
Practice Address - Country:US
Practice Address - Phone:772-464-9746
Practice Address - Fax:772-464-9750
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWAY SPECIALTY CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-08
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH29049261QM2500X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5726750OtherNCPDP