Provider Demographics
NPI:1932420247
Name:CAPRICORN HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:CAPRICORN HEALTHCARE SERVICES LLC
Other - Org Name:HILLSBORO SPECIALTY PHARMACY, BLOOD PRESSURE AND DIABETIC CE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADENIKE NIKI
Authorized Official - Middle Name:
Authorized Official - Last Name:GANSALLO
Authorized Official - Suffix:
Authorized Official - Credentials:BSC PHARMACY
Authorized Official - Phone:813-628-8400
Mailing Address - Street 1:4505 E HILLSBOROUGH AVE STE D&E
Mailing Address - Street 2:SUITE D & E
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-5200
Mailing Address - Country:US
Mailing Address - Phone:813-628-8400
Mailing Address - Fax:813-628-8484
Practice Address - Street 1:4505 E HILLSBOROUGH AVE STE D&E
Practice Address - Street 2:SUITE D & E
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-5200
Practice Address - Country:US
Practice Address - Phone:813-628-8400
Practice Address - Fax:813-628-8484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
FLPH246973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002675800Medicaid
2125531OtherPK
6747900001Medicare NSC