Provider Demographics
NPI:1831458868
Name:ST LUKE PHARMACY CORP
Entity Type:Organization
Organization Name:ST LUKE PHARMACY CORP
Other - Org Name:ST LUKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSALLAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-754-7851
Mailing Address - Street 1:2019 GULF TO BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-3703
Mailing Address - Country:US
Mailing Address - Phone:727-754-7851
Mailing Address - Fax:727-754-7852
Practice Address - Street 1:2019 GULF TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-3703
Practice Address - Country:US
Practice Address - Phone:727-754-7851
Practice Address - Fax:727-754-7852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-11
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH254163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008099500Medicaid
2135137OtherPK