Healthcare Provider Details

I. General information

NPI: 1063976777
Provider Name (Legal Business Name): HIYA RX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 E VAN FLEET DR
BARTOW FL
33830-7626
US

IV. Provider business mailing address

1140 E VAN FLEET DR
BARTOW FL
33830-7626
US

V. Phone/Fax

Practice location:
  • Phone: 352-804-0817
  • Fax:
Mailing address:
  • Phone: 352-804-0817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. PUSHPAKKUMAR D RAVAL
Title or Position: MEMBER
Credential:
Phone: 352-804-0817