Basic Information
| Provider Information | |||||||||
| NPI: | 1730112301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY CORPORATION OF AMERICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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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: | 6330 E 75TH ST | ||||||||
| Address2: | SUITE 322 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175956270 | ||||||||
| FaxNumber: | 3175956283 | ||||||||
| 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 | 3336H0001X | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336L0003X | 60005275A | IN | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0608530 | 05 | NJ | MEDICAID | 1730112301 | 05 | MI | MEDICAID | 1730112301 | 05 | CA | MEDICAID | 1730112301 | 05 | IA | MEDICAID | 10555500 | 05 | FL | MEDICAID | 1730112301 | 05 | CT | MEDICAID | 1671353 | 05 | AK | MEDICAID | 546608301 | 05 | MD | MEDICAID | UNK | 05 | AR | MEDICAID | 10025898302 | 05 | NE | MEDICAID | 1730112301 | 05 | ID | MEDICAID | 100292390A | 05 | IN | MEDICAID | 1730112301 | 05 | CO | MEDICAID | 1730112301 | 05 | NV | MEDICAID | 1529607 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 262456 | 05 | AZ | MEDICAID | 1730112301 | 05 | NC | MEDICAID | 600045200 | 05 | MO | MEDICAID | 7100484140 | 05 | KY | MEDICAID | 2139215 | 05 | OH | MEDICAID | 9538500000000 | 05 | IL | MEDICAID |