Provider Demographics
NPI:1699040055
Name:PRAETORIAN RX LLC
Entity Type:Organization
Organization Name:PRAETORIAN RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:813-929-0778
Mailing Address - Street 1:20429 AUTUMN FERN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2967
Mailing Address - Country:US
Mailing Address - Phone:186-623-2877
Mailing Address - Fax:
Practice Address - Street 1:20429 AUTUMN FERN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2967
Practice Address - Country:US
Practice Address - Phone:186-623-2877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center