Provider Demographics
NPI:1477731305
Name:MAHANT PHARMACY INC
Entity Type:Organization
Organization Name:MAHANT PHARMACY INC
Other - Org Name:FLORESTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:URMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:848-667-3791
Mailing Address - Street 1:1550 SE FLORESTA DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-4069
Mailing Address - Country:US
Mailing Address - Phone:772-340-4142
Mailing Address - Fax:772-785-5753
Practice Address - Street 1:1550 SE FLORESTA DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-4069
Practice Address - Country:US
Practice Address - Phone:772-340-4142
Practice Address - Fax:772-785-5753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BC3200X, 3336C0004X
FLPH305953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019934700Medicaid
FL019934700Medicaid
FL1032464Medicaid