Provider Demographics
NPI:1700194800
Name:D.Y.L. LLC
Entity Type:Organization
Organization Name:D.Y.L. LLC
Other - Org Name:SOUTH LAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER- MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEDRANO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH- PHARMD
Authorized Official - Phone:813-395-5667
Mailing Address - Street 1:38101 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-4973
Mailing Address - Country:US
Mailing Address - Phone:813-395-5667
Mailing Address - Fax:813-715-2478
Practice Address - Street 1:38101 5TH AVE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-4973
Practice Address - Country:US
Practice Address - Phone:813-395-5667
Practice Address - Fax:813-715-2478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH24899333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003197900Medicaid