Provider Demographics
NPI:1942740139
Name:TALLAHASSEE CANCER INSTITUTE PL
Entity Type:Organization
Organization Name:TALLAHASSEE CANCER INSTITUTE PL
Other - Org Name:TALLAHASSEE CANCER INSTITUTE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:AMER
Authorized Official - Middle Name:
Authorized Official - Last Name:RASSAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-219-8000
Mailing Address - Street 1:1653 MAHAN CENTER BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5454
Mailing Address - Country:US
Mailing Address - Phone:850-727-5502
Mailing Address - Fax:850-219-8003
Practice Address - Street 1:1653 MAHAN CENTER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5454
Practice Address - Country:US
Practice Address - Phone:850-727-5502
Practice Address - Fax:850-219-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH30628333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168070OtherPK