Provider Demographics
NPI:1255628095
Name:INTERNAL MEDICINE ASSOCIATES OF LEE COUNTY PHARMACY GROUP
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF LEE COUNTY PHARMACY GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-970-2263
Mailing Address - Street 1:13813 METRO PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4343
Mailing Address - Country:US
Mailing Address - Phone:239-938-1725
Mailing Address - Fax:205-970-6766
Practice Address - Street 1:13813 METRO PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4343
Practice Address - Country:US
Practice Address - Phone:239-938-1725
Practice Address - Fax:205-970-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336C0003X
FLPH25555333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5707407OtherNCPDP PROVIDER IDENTIFICATION NUMBER