MEDICARE: INDIAN RIVER PHARMACY

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	3336H0001X	Home Infusion Therapy Pharmacy	PH19077	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1001154	OTHER	FL	NCPDP

General Provider Information

NPI Number	:	1528274222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIAN RIVER PHARMACY

Provider Business Mailing Address
First Line	:	3719 10TH CT
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-6559
Country	:	US
Telephone Number	:	772-567-2557
Fax Number	:	772-567-0013

Provider Business Practice Location Address
First Line	:	3719 10TH CT
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-6559
Country	:	US
Telephone Number	:	772-567-2557
Fax Number	:	772-567-0013

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GREGORY MICHEAEL DECRESCENZO
Credential	:	R.PH.
Telephone Number	:	772-567-2557

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	08/22/2020

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Directions to “INDIAN RIVER PHARMACY ” Practice Location

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