Provider Demographics
NPI:1821083890
Name:HOMETOWN OLD COUNTRY PHARMACY, INC.
Entity Type:Organization
Organization Name:HOMETOWN OLD COUNTRY PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SATVIK
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-816-9770
Mailing Address - Street 1:8534 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICKEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654
Mailing Address - Country:US
Mailing Address - Phone:727-816-9770
Mailing Address - Fax:727-817-1310
Practice Address - Street 1:8534 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICKEY
Practice Address - State:FL
Practice Address - Zip Code:34654
Practice Address - Country:US
Practice Address - Phone:727-816-9770
Practice Address - Fax:727-817-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
FLPH21388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Yes3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002228400Medicaid
FL120435900Medicaid
FL5592650001Medicare NSC