Provider Demographics
NPI:1609323732
Name:FLORIDA MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:FLORIDA MEDICAL CLINIC LLC
Other - Org Name:FLORIDA MEDICAL CLINIC PHARMACY OF WIREGRASS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-715-0354
Mailing Address - Street 1:38045 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7504
Mailing Address - Country:US
Mailing Address - Phone:813-715-0354
Mailing Address - Fax:813-779-8049
Practice Address - Street 1:2352 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-9203
Practice Address - Country:US
Practice Address - Phone:813-751-3377
Practice Address - Fax:813-377-1672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
FLPH302493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164026OtherPK