Provider Demographics
NPI:1770870628
Name:LEGACY PARK DISCOUNT PHARMACY
Entity type:Organization
Organization Name:LEGACY PARK DISCOUNT PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ASHISHKUMAR
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-278-4422
Mailing Address - Street 1:10967 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-4457
Mailing Address - Country:US
Mailing Address - Phone:407-730-7989
Mailing Address - Fax:407-730-7995
Practice Address - Street 1:10967 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4457
Practice Address - Country:US
Practice Address - Phone:407-730-7989
Practice Address - Fax:407-730-7995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH255473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy