Provider Demographics
NPI:1710985544
Name:RADIANCE PHARMACY INC.
Entity Type:Organization
Organization Name:RADIANCE PHARMACY INC.
Other - Org Name:RADIANCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARAMCIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NWANDO
Authorized Official - Middle Name:OBIANUJU
Authorized Official - Last Name:NWANNA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:727-588-9878
Mailing Address - Street 1:110 CLEARWATER LARGO RD S
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3233
Mailing Address - Country:US
Mailing Address - Phone:727-588-9878
Mailing Address - Fax:727-588-9858
Practice Address - Street 1:110 CLEARWATER LARGO RD S
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3233
Practice Address - Country:US
Practice Address - Phone:727-588-9878
Practice Address - Fax:727-588-9858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH 20948332BD1200X
FLPH209483336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5389040001Medicare ID - Type UnspecifiedPROVIDER NUMBER