Provider Demographics
NPI:1558681460
Name:OPTUMCARE FLORIDA, LLC
Entity Type:Organization
Organization Name:OPTUMCARE FLORIDA, LLC
Other - Org Name:DAVITA MEDICAL GROUP, PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-205-6262
Mailing Address - Street 1:4757 US HIGHWAY 19
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-4945
Mailing Address - Country:US
Mailing Address - Phone:727-849-9373
Mailing Address - Fax:727-815-1203
Practice Address - Street 1:4757 US HIGHWAY 19 STE A
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4945
Practice Address - Country:US
Practice Address - Phone:727-849-9373
Practice Address - Fax:727-815-1203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH246343336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5700198OtherNCPDP PROVIDER IDENTIFICATION NUMBER