Provider Demographics
NPI:1881757417
Name:ST GEORGE PHARMACY INC
Entity type:Organization
Organization Name:ST GEORGE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MGR
Authorized Official - Prefix:
Authorized Official - First Name:SHADY
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDELMASIH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-772-6868
Mailing Address - Street 1:31201 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-4480
Mailing Address - Country:US
Mailing Address - Phone:727-772-6868
Mailing Address - Fax:727-772-6969
Practice Address - Street 1:31201 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-4480
Practice Address - Country:US
Practice Address - Phone:727-772-6868
Practice Address - Fax:727-772-6969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X, 332B00000X
FLPH188893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025840700Medicaid
2015172OtherPK