Provider Demographics
NPI:1770974750
Name:ADVANCE PHARMACY-2
Entity type:Organization
Organization Name:ADVANCE PHARMACY-2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:WALID
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDELMOTELEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-232-2700
Mailing Address - Street 1:4910 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-1402
Mailing Address - Country:US
Mailing Address - Phone:813-437-2100
Mailing Address - Fax:813-437-2101
Practice Address - Street 1:7926 W HILLSBOROUGH AVE STE E
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4600
Practice Address - Country:US
Practice Address - Phone:813-437-2100
Practice Address - Fax:813-437-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH28356333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014321800Medicaid