Provider Demographics
NPI:1477051217
Name:ATLANTIC PH LLC
Entity Type:Organization
Organization Name:ATLANTIC PH LLC
Other - Org Name:ATLANTIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIRMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NASR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-514-4694
Mailing Address - Street 1:3278 LAMANGA DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8524
Mailing Address - Country:US
Mailing Address - Phone:321-514-4694
Mailing Address - Fax:321-821-4971
Practice Address - Street 1:1525 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3540
Practice Address - Country:US
Practice Address - Phone:321-821-4998
Practice Address - Fax:321-821-4971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH311343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175640OtherPK
FL024459300Medicaid