Provider Demographics
NPI:1790070217
Name:GENERIC USA PHAMRACY INC
Entity Type:Organization
Organization Name:GENERIC USA PHAMRACY INC
Other - Org Name:GENERIC USA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-200-6011
Mailing Address - Street 1:6401 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-4048
Mailing Address - Country:US
Mailing Address - Phone:954-200-6011
Mailing Address - Fax:
Practice Address - Street 1:6401 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-4048
Practice Address - Country:US
Practice Address - Phone:954-200-6011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH245243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5706138OtherNCPDP PROVIDER IDENTIFICATION NUMBER