Provider Demographics
NPI:1588310239
Name:PINE BROOK PHARMACY LLC
Entity type:Organization
Organization Name:PINE BROOK PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMECKPEPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-610-4347
Mailing Address - Street 1:14111 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-2707
Mailing Address - Country:US
Mailing Address - Phone:352-610-4347
Mailing Address - Fax:352-610-4349
Practice Address - Street 1:14111 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2707
Practice Address - Country:US
Practice Address - Phone:352-610-4347
Practice Address - Fax:352-610-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001168201Medicaid