Provider Demographics
NPI:1538509278
Name:MILLENNIUM PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:MILLENNIUM PHYSICIAN GROUP LLC
Other - Org Name:MILLENNIUM PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE MGMNT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALTIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-856-3774
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:19531 COCHRAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2081
Practice Address - Country:US
Practice Address - Phone:855-674-7600
Practice Address - Fax:855-674-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH 269003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFM4241799OtherDEA REGISTRATION