Provider Demographics
NPI:1356534838
Name:PHARMACY VENTURES LLC
Entity type:Organization
Organization Name:PHARMACY VENTURES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-777-7000
Mailing Address - Street 1:PO BOX 223
Mailing Address - Street 2:
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-0223
Mailing Address - Country:US
Mailing Address - Phone:866-777-7000
Mailing Address - Fax:732-280-1350
Practice Address - Street 1:1850 ELDRON BLVD SE
Practice Address - Street 2:UNIT 7
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6870
Practice Address - Country:US
Practice Address - Phone:321-308-0303
Practice Address - Fax:321-308-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH269283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010536000Medicaid
2143471OtherPK
2143471OtherPK