Basic Information
| Provider Information | |||||||||
| NPI: | 1518064443 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY CORPORATION OF AMERICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 CORPOREX PARK DR | ||||||||
| Address2: | STE 150 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336191125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133186039 | ||||||||
| FaxNumber: | 8008256408 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 FAST ICE DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486426167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894967902 | ||||||||
| FaxNumber: | 8665823636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336H0001X | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336L0003X | 5301007447 | MI | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 50-2363808 | 05 | MI | MEDICAID | 87-4717701 | 05 | MI | MEDICAID | 2046094 | 01 | PK | OTHER |