Provider Demographics
NPI:1689686651
Name:FAMILY DRUGS OF INDIANTOWN LLC
Entity Type:Organization
Organization Name:FAMILY DRUGS OF INDIANTOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:RUCKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:772-597-2250
Mailing Address - Street 1:15690 SW WARFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:34956-3509
Mailing Address - Country:US
Mailing Address - Phone:772-597-2250
Mailing Address - Fax:772-597-2279
Practice Address - Street 1:15690 SW WARFIELD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANTOWN
Practice Address - State:FL
Practice Address - Zip Code:34956-3509
Practice Address - Country:US
Practice Address - Phone:772-597-2250
Practice Address - Fax:772-597-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH138673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103465101Medicaid
FL103465100Medicaid
1077519OtherNCPDP #