Provider Demographics
NPI:1508168576
Name:BLUE SKY DISCOUNT PHARMACY LLC
Entity Type:Organization
Organization Name:BLUE SKY DISCOUNT PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEADRA
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNTON-WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-914-0823
Mailing Address - Street 1:115 HICKORY ST
Mailing Address - Street 2:SUITE #101
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3505
Mailing Address - Country:US
Mailing Address - Phone:321-914-0823
Mailing Address - Fax:321-914-0824
Practice Address - Street 1:115 HICKORY ST
Practice Address - Street 2:SUITE #101
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3505
Practice Address - Country:US
Practice Address - Phone:321-914-0823
Practice Address - Fax:321-914-0824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH24968333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003753900Medicaid