Provider Demographics
NPI:1558596932
Name:PINE BROOK PHARMACY LLC
Entity Type:Organization
Organization Name:PINE BROOK PHARMACY LLC
Other - Org Name:PINE BROOK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-454-3426
Mailing Address - Street 1:14111 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-2707
Mailing Address - Country:US
Mailing Address - Phone:352-610-4347
Mailing Address - Fax:352-610-4349
Practice Address - Street 1:14111 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2707
Practice Address - Country:US
Practice Address - Phone:352-610-4347
Practice Address - Fax:352-610-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH240823336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6669650001Medicaid
2120453OtherPK