Provider Demographics
NPI:1598009573
Name:COASTAL SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:COASTAL SPECIALTY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGMR
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:850-622-3313
Mailing Address - Street 1:2050 W COUNTY HIGHWAY 30A
Mailing Address - Street 2:M1-106
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-0187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2050 W COUNTY HIGHWAY 30A
Practice Address - Street 2:M1-106
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-0187
Practice Address - Country:US
Practice Address - Phone:850-622-3315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy