Provider Demographics
NPI:1740530013
Name:GOLDTREE RX LLC
Entity type:Organization
Organization Name:GOLDTREE RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOBIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-827-4652
Mailing Address - Street 1:1401 SE GOLDTREE DR
Mailing Address - Street 2:UNIT 103
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7584
Mailing Address - Country:US
Mailing Address - Phone:772-237-4426
Mailing Address - Fax:
Practice Address - Street 1:1401 SE GOLDTREE DR STE 103
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7584
Practice Address - Country:US
Practice Address - Phone:772-237-4426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH261133336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5711773OtherNCPDP PROVIDER IDENTIFICATION NUMBER