Provider Demographics
NPI:1780103481
Name:ELLENTON DISCOUNT PHARMACY LLC
Entity type:Organization
Organization Name:ELLENTON DISCOUNT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KUNJAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-444-2233
Mailing Address - Street 1:8324 US HIGHWAY 301 N
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-8653
Mailing Address - Country:US
Mailing Address - Phone:941-444-2233
Mailing Address - Fax:941-417-7144
Practice Address - Street 1:8324 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-8653
Practice Address - Country:US
Practice Address - Phone:941-444-2233
Practice Address - Fax:941-417-7144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH298313336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017320800Medicaid
2175537OtherPK