Provider Demographics
NPI:1568535870
Name:GULF COAST MEDICAL PHARMACY INC
Entity Type:Organization
Organization Name:GULF COAST MEDICAL PHARMACY INC
Other - Org Name:GULF COAST MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-278-3969
Mailing Address - Street 1:13685 DOCTORS WAY
Mailing Address - Street 2:SUITE #150
Mailing Address - City:FT.MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912
Mailing Address - Country:US
Mailing Address - Phone:239-278-3969
Mailing Address - Fax:239-278-0336
Practice Address - Street 1:13685 DOCTORS WAY
Practice Address - Street 2:SUITE #150
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4336
Practice Address - Country:US
Practice Address - Phone:239-278-3969
Practice Address - Fax:239-278-0336
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GULF COAST MEDICAL PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-16
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH20076302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6211130001Medicare NSC