NPIViewer - Provider NPI 1366416448

NPI:	1366416448
Name:	PACIFICO NATIONAL INC
Entity type:	Organization
Organization Name:	PACIFICO NATIONAL INC
Other - Org Name:	<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:	PRES
Authorized Official - Prefix:
Authorized Official - First Name:	MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:	SANGREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:	321-872-0723
Mailing Address - Street 1:	1515 ELIZABETH ST
Mailing Address - Street 2:	STE J
Mailing Address - City:	MELBOURNE
Mailing Address - State:	FL
Mailing Address - Zip Code:	32901-3000
Mailing Address - Country:	US
Mailing Address - Phone:	321-872-0723
Mailing Address - Fax:	321-872-0721
Practice Address - Street 1:	1515 ELIZABETH ST
Practice Address - Street 2:	STE J
Practice Address - City:	MELBOURNE
Practice Address - State:	FL
Practice Address - Zip Code:	32901-3000
Practice Address - Country:	US
Practice Address - Phone:	321-872-0723
Practice Address - Fax:	321-872-0721
EIN:	<UNAVAIL>
Is Organization Subpart?:	No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:	2006-02-15
Last Update Date:	2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:

Primary?	Code	Type	Classification	Specialization
Yes	3336C0004X	Suppliers	Pharmacy	Compounding Pharmacy

State	Identifier ID	ID Type	Issuer
MN	1366416448	Medicaid
IL	1366416448	Medicaid
NH	226807	Medicaid
NJ	546330	Medicaid
WI	1000055714	Medicaid
ID	1366416448	Medicaid
UT	1366416448	Medicaid
OH	2856995	Medicaid
FL	02199910	Medicaid
AZ	134038	Medicaid
	2013120	Other	PK
IN	201352590A	Medicaid
KY	7100410000	Medicaid
NE	10026562600	Medicaid
VT	1028490	Medicaid
MD	105780400	Medicaid
OK	200647710A	Medicaid
NM	1366416448	Medicaid
WA	2059467	Medicaid
OR	500707688	Medicaid
NE	10026562600	Medicaid