Provider Demographics
NPI:1548835242
Name:BAYSIDE PHARMACY LLC
Entity type:Organization
Organization Name:BAYSIDE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:CHIRANJIVI
Authorized Official - Middle Name:B
Authorized Official - Last Name:JANNU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:813-395-6125
Mailing Address - Street 1:205 1ST ST S STE 106
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3266
Mailing Address - Country:US
Mailing Address - Phone:863-377-4774
Mailing Address - Fax:633-774-7448
Practice Address - Street 1:205 1ST ST S STE 106
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3266
Practice Address - Country:US
Practice Address - Phone:863-377-4774
Practice Address - Fax:633-774-7448
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYSIDE PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-25
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101Medicaid