Provider Demographics
NPI:1770828741
Name:ALPHA-OMEGA PHARMACY
Entity Type:Organization
Organization Name:ALPHA-OMEGA PHARMACY
Other - Org Name:ALPHA-OMEGA PHARMACY, L.L.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-557-0835
Mailing Address - Street 1:4625 E BAY DR STE 313
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-5747
Mailing Address - Country:US
Mailing Address - Phone:844-557-0835
Mailing Address - Fax:800-563-2710
Practice Address - Street 1:4625 E BAY DR STE 313
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-5747
Practice Address - Country:US
Practice Address - Phone:844-557-0835
Practice Address - Fax:800-563-2710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH265383336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138070OtherPK
FL008459101Medicaid
FL008459100Medicaid