Provider Demographics
NPI:1770873135
Name:ONE SOURCE PHARMACY OF BRADENTON
Entity type:Organization
Organization Name:ONE SOURCE PHARMACY OF BRADENTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MGR
Authorized Official - Prefix:
Authorized Official - First Name:INDRAJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:VYAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-490-8987
Mailing Address - Street 1:6404 OLD WINTER GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-1348
Mailing Address - Country:US
Mailing Address - Phone:877-490-8987
Mailing Address - Fax:877-490-8987
Practice Address - Street 1:3501 CORTEZ RD W
Practice Address - Street 2:UNIT 901B
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210
Practice Address - Country:US
Practice Address - Phone:877-490-8987
Practice Address - Fax:877-490-8987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONE SOURCE PHARMACY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH253993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy