Basic Information
Provider Information | |||||||||
NPI: | 1013028042 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHARMERICA EAST LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHARMERICA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3802 CORPOREX PARK DR STE 150 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336191135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8133186039 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 720 LAKEVIEW PLAZA BLVD | ||||||||
Address2: | SUITE H | ||||||||
City: | WORTHINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 43085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144309720 | ||||||||
FaxNumber: | 6144309732 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 10/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REED | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5023942100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 02788 | OH | Y |   | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 101402588-0002 | 05 | PA |   | MEDICAID | 2531433 | 05 | OH |   | MEDICAID | 200943370A | 05 | IN |   | MEDICAID | PSNH021508850 | 01 | OH | OH BOARD OF PHARMACY | OTHER | PSNH.021508850 | 01 | OH | BOARD OF PHARMACY | OTHER | MO0560122 | 01 | WV | WV BOARD OF PHARMACY | OTHER |