Provider Demographics
NPI:1962637496
Name:PALM COAST PHARMACY INC
Entity Type:Organization
Organization Name:PALM COAST PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VALERIY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAYTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-597-7400
Mailing Address - Street 1:9 PINE CONE DRIVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137
Mailing Address - Country:US
Mailing Address - Phone:386-597-7400
Mailing Address - Fax:386-246-7515
Practice Address - Street 1:9 PINE CONE DR
Practice Address - Street 2:SUITE 109
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8686
Practice Address - Country:US
Practice Address - Phone:386-597-7400
Practice Address - Fax:386-246-7515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
FLPH241883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001391500Medicaid
FP1622756OtherDEA