Provider Demographics
NPI:1720415599
Name:VILLA PHARMACY LLC
Entity Type:Organization
Organization Name:VILLA PHARMACY LLC
Other - Org Name:VILLA PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:SR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:813-215-9855
Mailing Address - Street 1:105 AVENUE R NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-2147
Mailing Address - Country:US
Mailing Address - Phone:813-215-9855
Mailing Address - Fax:
Practice Address - Street 1:105 AVENUE R NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:813-215-9855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH27110333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7513150001Medicare NSC