Provider Demographics
NPI:1497099055
Name:GIRIRAJ LLC
Entity Type:Organization
Organization Name:GIRIRAJ LLC
Other - Org Name:LAKEWALES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GOPIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-676-0400
Mailing Address - Street 1:1322 STAE RD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKEWALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853
Mailing Address - Country:US
Mailing Address - Phone:863-676-0400
Mailing Address - Fax:863-676-0445
Practice Address - Street 1:1322 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4322
Practice Address - Country:US
Practice Address - Phone:863-676-0400
Practice Address - Fax:863-676-0445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH265093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137946OtherPK