Provider Demographics
NPI:1851316731
Name:IDEL PHARMACY, INC
Entity Type:Organization
Organization Name:IDEL PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ILLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD MBA
Authorized Official - Phone:813-877-6679
Mailing Address - Street 1:3314 W COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1801
Mailing Address - Country:US
Mailing Address - Phone:813-877-6679
Mailing Address - Fax:813-877-1692
Practice Address - Street 1:3314 W COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1801
Practice Address - Country:US
Practice Address - Phone:813-877-6679
Practice Address - Fax:813-877-1692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH77903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104778700Medicaid
FL104778701Medicaid
FL0680210001Medicare NSC