Basic Information
| Provider Information | |||||||||
| NPI: | 1477550341 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY CORPORATION OF AMERICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LONG TERM PHARMACY SOLUTIONS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| 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: | 8008256408 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 STEDMAN ST | ||||||||
| Address2: | UNIT 27 | ||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018512700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784584000 | ||||||||
| FaxNumber: | 9784592485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA HOLDINGS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | 3184 | MA | N | Suppliers | Pharmacy | 3336C0004X | 3184 | MA | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336H0001X | 3184 | MA | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336S0011X | 3184 | MA | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336L0003X | 3184 | MA | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 110021711I | 05 | MA | MEDICAID | 2239639 | 01 | MA | NCPDP/NABP | OTHER |