Provider Demographics
NPI:1336209568
Name:DAVITA MEDICAL FLORIDA, INC.
Entity Type:Organization
Organization Name:DAVITA MEDICAL FLORIDA, INC.
Other - Org Name:DAVITA MEDICAL GROUP, PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HILGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-973-0777
Mailing Address - Street 1:10051 5TH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2299
Mailing Address - Country:US
Mailing Address - Phone:813-681-7888
Mailing Address - Fax:813-661-0843
Practice Address - Street 1:1931 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8819
Practice Address - Country:US
Practice Address - Phone:813-681-7888
Practice Address - Fax:813-661-0843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH130613336C0003X
3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030848000Medicaid
2013026OtherPK
FL4399230004Medicaid
FL030848000Medicaid