Provider Demographics
NPI:1013913680
Name:EXTENDED CARE PHARMACY, INC.
Entity Type:Organization
Organization Name:EXTENDED CARE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CASEY
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-325-5505
Mailing Address - Street 1:6400 CRILL AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3876
Mailing Address - Country:US
Mailing Address - Phone:386-325-5505
Mailing Address - Fax:386-328-9393
Practice Address - Street 1:6400 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3876
Practice Address - Country:US
Practice Address - Phone:386-325-5505
Practice Address - Fax:386-328-9393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032497300Medicaid
FL1088803OtherNCPDP
FL1301920001Medicare NSC