Provider Demographics
NPI:1013928514
Name:CARL D ACQUAVIVA
Entity Type:Organization
Organization Name:CARL D ACQUAVIVA
Other - Org Name:ACQUAVIVA'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:ACQUAVIVA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:321-725-7188
Mailing Address - Street 1:1555 PORT MALABAR BLVD NE
Mailing Address - Street 2:UNIT 101
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5407
Mailing Address - Country:US
Mailing Address - Phone:321-725-7188
Mailing Address - Fax:321-728-1333
Practice Address - Street 1:1555 PORT MALABAR BLVD NE
Practice Address - Street 2:UNIT 101
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5407
Practice Address - Country:US
Practice Address - Phone:321-725-7188
Practice Address - Fax:321-728-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
FLPH103163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1038036OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL104293901Medicaid
FL104293900Medicaid
1038036OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0132680001Medicare NSC