Basic Information
| Provider Information | |||||||||
| NPI: | 1639102213 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMERICA LONG TERM CARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | |||||||||
| Practice Location | |||||||||
| Address1: | 2720 BROADBENT PKWY NE STE A | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053431113 | ||||||||
| FaxNumber: | 5053439769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | PH00002000 | NM | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336L0003X | PH00002982 | NM | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 100045854 | 05 | WI | MEDICAID | PH000002982 | 01 | NM | BOARD OF PHARMACY | OTHER | PH00002982 | 01 | NM | BOARD OF PHARMACY | OTHER | 00062106 | 05 | NM | MEDICAID | 542622 | 05 | AZ | MEDICAID | CS00213189 | 01 | NM | CONTROLLED SUBSTANCE | OTHER |