Provider Demographics
NPI:1982956702
Name:5M PHARMA LLC
Entity Type:Organization
Organization Name:5M PHARMA LLC
Other - Org Name:SPECTRUM DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:VIRAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-968-9100
Mailing Address - Street 1:6056 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-8000
Mailing Address - Country:US
Mailing Address - Phone:813-968-9100
Mailing Address - Fax:813-968-9200
Practice Address - Street 1:6056 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8000
Practice Address - Country:US
Practice Address - Phone:813-968-9100
Practice Address - Fax:813-968-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH265223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008444000Medicaid
2137240OtherPK