MEDICARE: GONCAN 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
2	3336C0003X	Community/Retail Pharmacy	PH24941	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5702231	OTHER	NCPDP PROVIDER IDENTIFICATION NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326358516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GONCAN INC

Provider Business Mailing Address
First Line	:	800 VIRGINIA AVE
Second Line	:	SUITE #33
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5829
Country	:	US
Telephone Number	:	772-882-4785
Fax Number	:	772-519-9982

Provider Business Practice Location Address
First Line	:	800 VIRGINIA AVE
Second Line	:	SUITE #33
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5829
Country	:	US
Telephone Number	:	772-882-4785
Fax Number	:	772-519-9982

Authorized Official
Title or Position	:	PRESCRIPTION DEPT.MANAGER
Name	:	GODWIN NWAOBI
Credential	:
Telephone Number	:	772-882-4785

Provider Enumeration Date	:	10/21/2010
Last Update Date	:	02/01/2013

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Directions to “GONCAN INC ” Practice Location

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