Provider Demographics
NPI:1821217910
Name:PHARMACY CORPORATION OF AMERICA
Entity Type:Organization
Organization Name:PHARMACY CORPORATION OF AMERICA
Other - Org Name:PREMIER LONG TERM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CANERIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-627-7100
Mailing Address - Street 1:3802 CORPOREX PARK DR STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-1135
Mailing Address - Country:US
Mailing Address - Phone:813-318-6039
Mailing Address - Fax:800-825-6408
Practice Address - Street 1:1618 S LANE ST STE 204
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144
Practice Address - Country:US
Practice Address - Phone:206-323-0868
Practice Address - Fax:206-323-9206
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHARMERICA CORPORATE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-25
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
WACF000590243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6029987Medicaid
4932326OtherNCPDP PROVIDER IDENTIFICATION NUMBER