Provider Demographics
NPI:1295162709
Name:MODEL PHARMACY
Entity type:Organization
Organization Name:MODEL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SATVIK
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-622-2510
Mailing Address - Street 1:1714 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-3307
Mailing Address - Country:US
Mailing Address - Phone:407-572-8779
Mailing Address - Fax:407-572-8780
Practice Address - Street 1:1714 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3307
Practice Address - Country:US
Practice Address - Phone:407-572-8779
Practice Address - Fax:407-572-8780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-28
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012220900Medicaid