Provider Demographics
NPI:1255615381
Name:TAVARES PHARMACY LLC
Entity type:Organization
Organization Name:TAVARES PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANWAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-455-3483
Mailing Address - Street 1:524 S DUNCAN DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4146
Mailing Address - Country:US
Mailing Address - Phone:352-508-6449
Mailing Address - Fax:352-508-6448
Practice Address - Street 1:524 S DUNCAN DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4146
Practice Address - Country:US
Practice Address - Phone:352-508-6449
Practice Address - Fax:352-508-6448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH256973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132257OtherPK
FL004350300Medicaid