Basic Information
| Provider Information | |||||||||
| NPI: | 1801802210 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY CORPORATION OF AMERICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHAR MERICA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 CORPOREX PARK DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336191125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133186039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1100 WILSON WAY | ||||||||
| Address2: | STE 500 | ||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704321621 | ||||||||
| FaxNumber: | 8007223599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/24/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANERIS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5026277100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1558559 | 05 | LA | MEDICAID | 200264800A | 05 | IN | MEDICAID | 000255516B | 05 | GA | MEDICAID | 100080240D | 05 | KS | MEDICAID | 9151500 | 05 | SD | MEDICAID | 009610640 | 05 | AL | MEDICAID | 106298101 | 05 | FL | MEDICAID | 55365 | 05 | ND | MEDICAID | 622449114 | 05 | MO | MEDICAID | 009149368 | 05 | VA | MEDICAID | 33037000 | 05 | WI | MEDICAID | 7701221 | 05 | NC | MEDICAID | 0392427 | 05 | OH | MEDICAID | 150921801 | 05 | TX | MEDICAID | 1801802210 | 05 | CT | MEDICAID | 3541753 | 05 | TN | MEDICAID | 9000795600 | 05 | KY | MEDICAID | PC72436 | 05 | RI | MEDICAID | 033685800 | 05 | DC | MEDICAID | 30009810 | 05 | NH | MEDICAID | 377417000 | 05 | MN | MEDICAID | 661057900 | 05 | MN | MEDICAID | 8082344 | 05 | ID | MEDICAID | 00040355 | 05 | MS | MEDICAID | 1007739010019 | 05 | PA | MEDICAID | 200035360C | 05 | OK | MEDICAID | 4914077 | 05 | MI | MEDICAID |