Provider Demographics
NPI:1659764959
Name:AVA KEROLOS LLC
Entity Type:Organization
Organization Name:AVA KEROLOS LLC
Other - Org Name:GOOD SAMARITAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUFAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-554-8105
Mailing Address - Street 1:33338 U.S. HWY 19 N.
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684
Mailing Address - Country:US
Mailing Address - Phone:727-785-2650
Mailing Address - Fax:727-785-2827
Practice Address - Street 1:33338 U.S. HWY 19 N.
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-785-2640
Practice Address - Fax:727-784-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH288673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014789900Medicaid
2150855OtherPK