Basic Information
| Provider Information | |||||||||
| NPI: | 1639735228 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY CORPORATION OF AMERICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 18110 SE 34TH ST STE 270 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986839440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036269436 | ||||||||
| FaxNumber: | 8443083027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2019 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA HOLDINGS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336M0002X | N | Suppliers | Pharmacy | Mail Order Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0666179 | 05 | MT | MEDICAID | 1702409 | 05 | AK | MEDICAID | 2142140 | 05 | WA | MEDICAID | 1702169 | 05 | AK | MEDICAID | 156273800 | 05 | WY | MEDICAID | 1639735228 | 05 | ID | MEDICAID | 1700643 | 05 | AK | MEDICAID | 500772702 | 05 | OR | MEDICAID |