Provider Demographics
NPI:1568613180
Name:UNIVERSITY OF SOUTH FLORIDA BOARD OF TRUSTEES
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTH FLORIDA BOARD OF TRUSTEES
Other - Org Name:USF BULLS COUNTRY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCCIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-974-2331
Mailing Address - Street 1:12530 USF BULL RUN DRIVE
Mailing Address - Street 2:SWC 310
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33620
Mailing Address - Country:US
Mailing Address - Phone:813-974-2074
Mailing Address - Fax:813-974-4383
Practice Address - Street 1:12530 USF BULL RUN DRIVE
Practice Address - Street 2:SWC 310
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620
Practice Address - Country:US
Practice Address - Phone:813-974-2071
Practice Address - Fax:813-974-4383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH235263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115486200Medicaid
2117253OtherPK