Provider Demographics
NPI:1295933299
Name:MANASOTA PHARMACY SERVICES LLC
Entity type:Organization
Organization Name:MANASOTA PHARMACY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:REISKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-727-9120
Mailing Address - Street 1:1407 57TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-3646
Mailing Address - Country:US
Mailing Address - Phone:941-727-9120
Mailing Address - Fax:941-727-9122
Practice Address - Street 1:1407 57TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3646
Practice Address - Country:US
Practice Address - Phone:941-727-9120
Practice Address - Fax:941-727-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336S0011X
FLPH254113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132643OtherPK
FL003702200Medicaid