Provider Demographics
NPI:1720093339
Name:APOTHECARY SHOP
Entity Type:Organization
Organization Name:APOTHECARY SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-676-1174
Mailing Address - Street 1:437 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:437 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4250
Practice Address - Country:US
Practice Address - Phone:863-676-1174
Practice Address - Fax:863-676-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH006754333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP3131OtherBCBS OF FLORIDA
1013553OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FLP3131OtherBCBS OF FLORIDA