Provider Demographics
NPI:1649593179
Name:ANNALICE LLC
Entity Type:Organization
Organization Name:ANNALICE LLC
Other - Org Name:PEGASUS RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:OHIHOIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-534-1318
Mailing Address - Street 1:1992 ALT US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689
Mailing Address - Country:US
Mailing Address - Phone:727-938-6400
Mailing Address - Fax:
Practice Address - Street 1:1992 ALT US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689
Practice Address - Country:US
Practice Address - Phone:727-938-6400
Practice Address - Fax:727-938-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
FLPH244813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002335600Medicaid
2124203OtherPK