Provider Demographics
NPI:1811451834
Name:DAYTONA SPECIALTY LLC
Entity type:Organization
Organization Name:DAYTONA SPECIALTY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MALAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-241-0321
Mailing Address - Street 1:1700 FROGS LEAP CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-4046
Mailing Address - Country:US
Mailing Address - Phone:386-334-4920
Mailing Address - Fax:
Practice Address - Street 1:780 DUNLAWTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4252
Practice Address - Country:US
Practice Address - Phone:386-241-0321
Practice Address - Fax:386-241-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH31235OtherPHARMACY LICENSE