Provider Demographics
NPI:1265868665
Name:WICKHAM DISCOUNT PHARMACY LLC
Entity type:Organization
Organization Name:WICKHAM DISCOUNT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHCY MGR, PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANKIT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:321-241-6433
Mailing Address - Street 1:1060 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8937
Mailing Address - Country:US
Mailing Address - Phone:321-241-6433
Mailing Address - Fax:321-241-6434
Practice Address - Street 1:1060 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8937
Practice Address - Country:US
Practice Address - Phone:321-241-6433
Practice Address - Fax:321-241-6434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-18
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH269063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010488000Medicaid
2142537OtherPK