Provider Demographics
NPI:1891184859
Name:PRESCRIPTION PLACE OF NICEVILLE LLC
Entity Type:Organization
Organization Name:PRESCRIPTION PLACE OF NICEVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ABBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-389-8182
Mailing Address - Street 1:1140 JOHN SIMS PKWY E
Mailing Address - Street 2:SUITE 6
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2204
Mailing Address - Country:US
Mailing Address - Phone:850-892-6898
Mailing Address - Fax:850-389-8182
Practice Address - Street 1:1140 JOHN SIMS PKWY E
Practice Address - Street 2:SUITE 6
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2204
Practice Address - Country:US
Practice Address - Phone:850-389-8182
Practice Address - Fax:850-389-8185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH288013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014786600Medicaid
FLPH28801OtherFLORIDA STATE LICENSE
FLID221AMedicare PIN
FL014786600Medicaid