Provider Demographics
NPI:1336440890
Name:CITIPHARM INC
Entity Type:Organization
Organization Name:CITIPHARM INC
Other - Org Name:BAY AREA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:BANJOKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-341-4000
Mailing Address - Street 1:PO BOX 17175
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-7175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 S MILITARY TRAIL
Practice Address - Street 2:SUITE I-2
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-5641
Practice Address - Country:US
Practice Address - Phone:561-268-0888
Practice Address - Fax:561-268-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20Medicaid
FL104325700Medicaid