Provider Demographics
NPI:1689319709
Name:MIDWAY SPECIALTY CARE RX LLC.
Entity Type:Organization
Organization Name:MIDWAY SPECIALTY CARE RX LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:772-464-9746
Mailing Address - Street 1:3255 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-6381
Mailing Address - Country:US
Mailing Address - Phone:772-464-9746
Mailing Address - Fax:
Practice Address - Street 1:5224 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-2147
Practice Address - Country:US
Practice Address - Phone:813-733-0602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWAY SPECIALTY CARE CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH33929OtherPHARMACY LICENSE