Provider Demographics
NPI:1902220197
Name:GOLDENROD PHARMACY LLC
Entity Type:Organization
Organization Name:GOLDENROD PHARMACY LLC
Other - Org Name:GOLDENROD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANUPAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:BODDAPATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-474-9393
Mailing Address - Street 1:2223 S GOLDENROD RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-4676
Mailing Address - Country:US
Mailing Address - Phone:407-730-3866
Mailing Address - Fax:
Practice Address - Street 1:2223 S GOLDENROD RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-4676
Practice Address - Country:US
Practice Address - Phone:407-730-3866
Practice Address - Fax:407-730-3347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH274373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011063200Medicaid
2144154OtherPK