Basic Information
| Provider Information | |||||||||
| NPI: | 1821217910 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMACY CORPORATION OF AMERICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PREMIER LONG TERM CARE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 8008256408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1618 S LANE ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063230868 | ||||||||
| FaxNumber: | 2063239206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANERIS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5026277100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA CORPORATE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 6029987 | 05 | WA | MEDICAID | 4932326 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |