Provider Demographics
NPI:1265699946
Name:FERTILITY PHARMACY
Entity type:Organization
Organization Name:FERTILITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-557-2029
Mailing Address - Street 1:120 W STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-2551
Mailing Address - Country:US
Mailing Address - Phone:407-557-2029
Mailing Address - Fax:480-247-5681
Practice Address - Street 1:120 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-2551
Practice Address - Country:US
Practice Address - Phone:407-557-2029
Practice Address - Fax:480-247-5681
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LBG HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-20
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH23353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008795700Medicaid