Basic Information
| Provider Information | |||||||||
| NPI: | 1033139944 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMERICA DRUG SYSTEMS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 CORPOREX PARK DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336191125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133186039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9386 HARDY ROAD | ||||||||
| Address2: | |||||||||
| City: | VINTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408907788 | ||||||||
| FaxNumber: | 5408907337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 0201002873 | VA | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 008506388 | 05 | VA | MEDICAID | 4142713 00 | 05 | MD | MEDICAID | 1033139944 | 05 | VA | MEDICAID |