Provider Demographics
NPI:1952776536
Name:TAMPA PALMS PHARMACY LLC
Entity Type:Organization
Organization Name:TAMPA PALMS PHARMACY LLC
Other - Org Name:TAMPA PALMS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOBY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:352-678-1882
Mailing Address - Street 1:15309 AMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2112
Mailing Address - Country:US
Mailing Address - Phone:352-678-1882
Mailing Address - Fax:813-252-7146
Practice Address - Street 1:15309 AMBERLY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2112
Practice Address - Country:US
Practice Address - Phone:813-605-0300
Practice Address - Fax:813-605-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH294273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155763OtherPK
FL016338700Medicaid