Provider Demographics
NPI:1184063455
Name:XTRA CARE PHARMACY INC
Entity type:Organization
Organization Name:XTRA CARE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-598-0593
Mailing Address - Street 1:6520 US HIGHWAY 301 S
Mailing Address - Street 2:SUITE 106
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4347
Mailing Address - Country:US
Mailing Address - Phone:813-280-0927
Mailing Address - Fax:813-677-4500
Practice Address - Street 1:6520 US HIGHWAY 301 S STE 106
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-4324
Practice Address - Country:US
Practice Address - Phone:813-280-0927
Practice Address - Fax:813-677-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-20
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH267123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009181900Medicaid
2140629OtherPK