Basic Information
| Provider Information | |||||||||
| NPI: | 1285667865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY CORPORATION OF AMERICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 CORPOREX PARK DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336191135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133186039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5255 E RIVER RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554211026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635712220 | ||||||||
| FaxNumber: | 7635713311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336L0003X | 2615480 | MN | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2406785 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 939108 | 05 | IA | MEDICAID | 2406785 | 05 | MI | MEDICAID | 2406785 | 05 | IA | MEDICAID | 8532032 | 05 | SD | MEDICAID | 9151500 | 05 | SD | MEDICAID | 200526100A | 05 | IN | MEDICAID | 33037000 | 05 | WI | MEDICAID | 7M1548 | 05 | SC | MEDICAID | 1285667865 | 05 | WI | MEDICAID | 661057900 | 05 | MN | MEDICAID |