Provider Demographics
NPI:1578715215
Name:HEPZIBAH INC
Entity Type:Organization
Organization Name:HEPZIBAH INC
Other - Org Name:SRX PHARMACY #002
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, VP, AO
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-484-8611
Mailing Address - Street 1:3500 E FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4708
Mailing Address - Country:US
Mailing Address - Phone:813-413-8242
Mailing Address - Fax:813-413-8302
Practice Address - Street 1:10802 MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:THONOTOSASSA
Practice Address - State:FL
Practice Address - Zip Code:33592-2840
Practice Address - Country:US
Practice Address - Phone:813-413-8242
Practice Address - Fax:813-413-8302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH235463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001349300Medicaid
2117414OtherPK