Provider Demographics
NPI:1710072830
Name:WORLD TRIUMPH MEDICAL
Entity Type:Organization
Organization Name:WORLD TRIUMPH MEDICAL
Other - Org Name:WORLD TRIUMPH MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MNGER
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPH
Authorized Official - Phone:941-366-0090
Mailing Address - Street 1:2850 RINGLING BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-5346
Mailing Address - Country:US
Mailing Address - Phone:941-366-0090
Mailing Address - Fax:941-954-5535
Practice Address - Street 1:2850 RINGLING BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-5346
Practice Address - Country:US
Practice Address - Phone:941-366-0090
Practice Address - Fax:941-954-5535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH141973336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101129400Medicaid
1035915OtherNCPDP PROVIDER IDENTIFICATION NUMBER