Provider Demographics
NPI:1497209159
Name:PALMYRA PHARMACY LLC
Entity Type:Organization
Organization Name:PALMYRA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:HARAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-213-3815
Mailing Address - Street 1:13060 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-4854
Mailing Address - Country:US
Mailing Address - Phone:352-600-7572
Mailing Address - Fax:352-600-7675
Practice Address - Street 1:13080 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-4854
Practice Address - Country:US
Practice Address - Phone:352-600-7572
Practice Address - Fax:352-600-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL303003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019942700Medicaid