Provider Demographics
NPI:1578198560
Name:ECKERDS PHARMACY LLC
Entity Type:Organization
Organization Name:ECKERDS PHARMACY LLC
Other - Org Name:VISTARA SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BHAVESHKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-900-4995
Mailing Address - Street 1:4404 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:KENNETH CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33709-4922
Mailing Address - Country:US
Mailing Address - Phone:727-513-1107
Mailing Address - Fax:727-513-1109
Practice Address - Street 1:4404 66TH ST N
Practice Address - Street 2:
Practice Address - City:KENNETH CITY
Practice Address - State:FL
Practice Address - Zip Code:33709-4922
Practice Address - Country:US
Practice Address - Phone:727-513-1107
Practice Address - Fax:727-513-1109
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ECKERDS PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-10
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101899100Medicaid