Basic Information
Provider Information | |||||||||
NPI: | 1811920499 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHARMERICA LONG TERM CARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHARMERICA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3802 CORPOREX PARK DR | ||||||||
Address2: | STE 200 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336191125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8133186039 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 625 CENTRAL AVE W | ||||||||
Address2: | SUITE 105 | ||||||||
City: | GREAT FALLS | ||||||||
State: | MT | ||||||||
PostalCode: | 594042874 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8007573713 | ||||||||
FaxNumber: | 8002951662 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2006 | ||||||||
LastUpdateDate: | 10/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 06/11/2018 | ||||||||
NPIReactivationDate: | 01/23/2019 | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REED | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5023942100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 1065 | MT | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 3336L0003X | 1065 | MT | N |   | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336L0003X | 1229 | MT | Y |   | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 1811920499 | 05 | MT |   | MEDICAID | FP8229812 | 01 | MT | DEA | OTHER | PHA-PHR-LIC-58716 | 01 | MT | BOARD OF PHARMACY | OTHER |