Provider Demographics
NPI:1518109685
Name:UMBRA INC
Entity Type:Organization
Organization Name:UMBRA INC
Other - Org Name:4TH ST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ENERIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-476-0854
Mailing Address - Street 1:5415 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-2249
Mailing Address - Country:US
Mailing Address - Phone:727-329-8798
Mailing Address - Fax:727-329-8800
Practice Address - Street 1:5415 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-2249
Practice Address - Country:US
Practice Address - Phone:727-329-8798
Practice Address - Fax:727-329-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH239913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001669500106Medicaid
2119880OtherPK