MEDICARE: TRELLES MEMORIAL CLINIC AND HOSPITAL INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	PH11093	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1068558	OTHER	FL	NCPDP

General Provider Information

NPI Number	:	1184624843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRELLES MEMORIAL CLINIC AND HOSPITAL INC.

Provider Business Mailing Address
First Line	:	P.O. BOX 89039-0400
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33689-9039
Country	:	US
Telephone Number	:	813-662-1153
Fax Number	:	813-657-3475

Provider Business Practice Location Address
First Line	:	3501 RIGA BLVD
Second Line	:	SUITE 300B
City	:	TAMPA
State	:	FL
Zip	:	33619-1333
Country	:	US
Telephone Number	:	813-662-1153
Fax Number	:	813-657-3475

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MR. JAMES CLEAVER RICHARDSON
Credential	:	RPH
Telephone Number	:	813-662-1153

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	08/22/2020

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