Provider Demographics
NPI:1508003138
Name:PIERSON COMMUNITY PHARMACY INC
Entity Type:Organization
Organization Name:PIERSON COMMUNITY PHARMACY INC
Other - Org Name:PIERSON COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,AO
Authorized Official - Prefix:
Authorized Official - First Name:HANAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANCIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-738-6268
Mailing Address - Street 1:112 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PIERSON
Mailing Address - State:FL
Mailing Address - Zip Code:32180-3039
Mailing Address - Country:US
Mailing Address - Phone:386-749-9557
Mailing Address - Fax:386-749-9512
Practice Address - Street 1:650 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3260
Practice Address - Country:US
Practice Address - Phone:386-738-6268
Practice Address - Fax:386-738-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH234523336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000987601Medicaid
FL000987600Medicaid
2118550OtherPK