Provider Demographics
NPI:1962457796
Name:VILLAGE PHARMACY OF NOKOMIS LLC
Entity Type:Organization
Organization Name:VILLAGE PHARMACY OF NOKOMIS LLC
Other - Org Name:VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:941-488-8800
Mailing Address - Street 1:1095 TAMIAMI TRL N
Mailing Address - Street 2:STE B
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-2114
Mailing Address - Country:US
Mailing Address - Phone:941-488-8800
Mailing Address - Fax:941-488-8802
Practice Address - Street 1:1095 TAMIAMI TRL N
Practice Address - Street 2:STE B
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-2114
Practice Address - Country:US
Practice Address - Phone:941-488-8800
Practice Address - Fax:941-488-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X, 3336S0011X
FLPH219193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2006650OtherPK
FL031574501OtherMEDICAID DME
FL031574500Medicaid
1018577OtherNCPDP PROVIDER IDENTIFICATION NUMBER