Provider Demographics
NPI:1821308305
Name:PEPPER TREE PHARMACY
Entity Type:Organization
Organization Name:PEPPER TREE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AYOTUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-622-5601
Mailing Address - Street 1:1907 SE 58TH AVE
Mailing Address - Street 2:ROLLING GREENS SHOPPING CENTER
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-5847
Mailing Address - Country:US
Mailing Address - Phone:352-622-5601
Mailing Address - Fax:352-622-5612
Practice Address - Street 1:1907 SE 58TH AVE
Practice Address - Street 2:ROLLING GREENS SHOPPING CENTER
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34480-5847
Practice Address - Country:US
Practice Address - Phone:352-622-5601
Practice Address - Fax:352-622-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03129600Medicaid
FLPH 25060OtherPHARMACY LICENSE #