MEDICARE: AGNES RX 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	PH26103	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1042768	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1467690214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGNES RX INC

Provider Business Mailing Address
First Line	:	2800 N MACDILL AVE
Second Line	:	STE C
City	:	TAMPA
State	:	FL
Zip	:	33607-2208
Country	:	US
Telephone Number	:	813-870-6300
Fax Number	:	813-870-6904

Provider Business Practice Location Address
First Line	:	2800 N MACDILL AVE
Second Line	:	STE C
City	:	TAMPA
State	:	FL
Zip	:	33607-2208
Country	:	US
Telephone Number	:	813-870-6300
Fax Number	:	813-870-6904

Authorized Official
Title or Position	:	PRESIDENT/PHARMACIST
Name	:	AGNES PARK
Credential	:
Telephone Number	:	813-870-6300

Provider Enumeration Date	:	02/02/2009
Last Update Date	:	02/14/2013

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