Provider Demographics
NPI:1740673235
Name:OCOEE PHARMACY, INC
Entity type:Organization
Organization Name:OCOEE PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:423-506-6243
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:TN
Mailing Address - Zip Code:37361-0297
Mailing Address - Country:US
Mailing Address - Phone:423-299-9029
Mailing Address - Fax:423-299-9250
Practice Address - Street 1:186 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:TN
Practice Address - Zip Code:37361
Practice Address - Country:US
Practice Address - Phone:423-299-9029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy