Provider Demographics
NPI:1871664888
Name:NEWBERRY PHARMACY INC
Entity Type:Organization
Organization Name:NEWBERRY PHARMACY INC
Other - Org Name:HOMETOWN PHARMACY - NEWBERRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY-JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAINGER-ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD RPH
Authorized Official - Phone:352-472-9001
Mailing Address - Street 1:24220 W NEWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-2211
Mailing Address - Country:US
Mailing Address - Phone:352-472-9001
Mailing Address - Fax:352-472-8776
Practice Address - Street 1:24220 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-2211
Practice Address - Country:US
Practice Address - Phone:352-472-9001
Practice Address - Fax:352-472-8776
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MARKETS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2014953OtherPK
FL000665000Medicaid
FL000665001 DMEMedicaid
6254050001Medicare NSC