Provider Demographics
NPI:1912253774
Name:MARIETTA PHARMACY LLC
Entity Type:Organization
Organization Name:MARIETTA PHARMACY LLC
Other - Org Name:MARIETTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RXM
Authorized Official - Prefix:
Authorized Official - First Name:HANESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-999-4884
Mailing Address - Street 1:8299 W BEAVER ST STE 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32220-2315
Mailing Address - Country:US
Mailing Address - Phone:904-999-4884
Mailing Address - Fax:904-999-4883
Practice Address - Street 1:8299 W BEAVER ST STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32220-2315
Practice Address - Country:US
Practice Address - Phone:904-999-4884
Practice Address - Fax:904-999-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
FLPH262853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007212200Medicaid
5711189OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL6743710001Medicare NSC