Basic Information
| Provider Information | |||||||||
| NPI: | 1558394130 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY CORPORATION OF AMERICA | ||||||||
| 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: | 350 MYLES STANDISH BLVD STE 104 | ||||||||
| Address2: | |||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027807387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084275000 | ||||||||
| FaxNumber: | 5085873645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
| 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 | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 333600000X | 2796 | MA | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336L0003X | 3599 | MA | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0192091 | 05 | NJ | MEDICAID | 1004936 | 05 | VT | MEDICAID | 004128600 | 05 | CT | MEDICAID | 1002841 | 05 | VT | MEDICAID | 194400001 | 05 | ME | MEDICAID | 02206417 | 05 | NY | MEDICAID | 2235112 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 010319153 | 05 | VA | MEDICAID | 03179917 | 05 | NY | MEDICAID | 1558394130 | 05 | DE | MEDICAID | 110022080A | 05 | MA | MEDICAID | 30009810 | 05 | NH | MEDICAID | DR00409 | 05 | RI | MEDICAID | 1558394130 | 05 | IL | MEDICAID | 1558394130 | 05 | VA | MEDICAID | 0423131 | 05 | MA | MEDICAID | 1558394130 | 05 | ME | MEDICAID | 187440000 | 05 | ME | MEDICAID |