Provider Demographics
NPI:1942509401
Name:SOUTH WALTON PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTH WALTON PHARMACY LLC
Other - Org Name:SANTA ROSA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:E
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-622-3313
Mailing Address - Street 1:2050 W COUNTY HIGHWAY 30A
Mailing Address - Street 2:M1-106
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-0187
Mailing Address - Country:US
Mailing Address - Phone:850-622-3313
Mailing Address - Fax:850-622-3255
Practice Address - Street 1:2050 W COUNTY HIGHWAY 30A UNIT M1-106
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-0187
Practice Address - Country:US
Practice Address - Phone:850-622-3313
Practice Address - Fax:850-622-3255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH254283336C0003X
3336H0001X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117267300Medicaid
2130225OtherPK