Provider Demographics
NPI:1134234164
Name:LINCOURT PHARMACY CORP
Entity type:Organization
Organization Name:LINCOURT PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BANJOKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-341-4000
Mailing Address - Street 1:PO BOX 17175
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-7175
Mailing Address - Country:US
Mailing Address - Phone:727-447-4248
Mailing Address - Fax:727-445-9604
Practice Address - Street 1:501 S LINCOLN AVE
Practice Address - Street 2:STE 10
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5945
Practice Address - Country:US
Practice Address - Phone:727-447-4248
Practice Address - Fax:727-445-9604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
FLPH87253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102009900Medicaid
2003908OtherPK
FL0704500001Medicare NSC