Provider Demographics
NPI:1518366319
Name:DIRECT RETAIL PHARMACY LLC
Entity Type:Organization
Organization Name:DIRECT RETAIL PHARMACY LLC
Other - Org Name:DIRECT RETAIL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AN
Authorized Official - Middle Name:DUC
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-406-1447
Mailing Address - Street 1:5060 S CONWAY RD STE #1
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812
Mailing Address - Country:US
Mailing Address - Phone:407-203-0005
Mailing Address - Fax:407-480-5355
Practice Address - Street 1:5060 S CONWAY RD STE #1
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812
Practice Address - Country:US
Practice Address - Phone:407-203-0005
Practice Address - Fax:407-480-5355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIRECT RETAIL PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-18
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSS50205333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013810000Medicaid