Provider Demographics
NPI:1558657718
Name:AMICITIA PHARMA LLC
Entity Type:Organization
Organization Name:AMICITIA PHARMA LLC
Other - Org Name:1ST CHOICE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOKHA
Authorized Official - Middle Name:
Authorized Official - Last Name:YIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:727-954-8877
Mailing Address - Street 1:4105 49TH ST N STE B
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-5711
Mailing Address - Country:US
Mailing Address - Phone:727-954-8877
Mailing Address - Fax:727-329-8872
Practice Address - Street 1:4105 49TH ST N STE B
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-5711
Practice Address - Country:US
Practice Address - Phone:727-954-8877
Practice Address - Fax:727-329-8872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH255303336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003884500Medicaid
2130819OtherPK