Provider Demographics
NPI:1508120395
Name:MERRITT ISLAND PHARMACY
Entity Type:Organization
Organization Name:MERRITT ISLAND PHARMACY
Other - Org Name:MERRITT ISLAND DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:BHAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DHADUK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:201-916-7125
Mailing Address - Street 1:35 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3476
Mailing Address - Country:US
Mailing Address - Phone:321-454-0911
Mailing Address - Fax:321-459-2479
Practice Address - Street 1:35 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3476
Practice Address - Country:US
Practice Address - Phone:321-454-0911
Practice Address - Fax:321-459-2479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336C0004X
FLPH262033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135755OtherPK
FL007812301Medicaid
2135755OtherPK