Healthcare Provider Details

I. General information

NPI: 1538529060
Provider Name (Legal Business Name): GULF MED PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 12/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 DEL PRADO BLVD S
CAPE CORAL FL
33904-7163
US

IV. Provider business mailing address

4106 DEL PRADO BLVD S
CAPE CORAL FL
33904-7163
US

V. Phone/Fax

Practice location:
  • Phone: 239-542-1291
  • Fax: 239-542-1292
Mailing address:
  • Phone: 239-542-1291
  • Fax: 239-542-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH30406
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GUERDITH FERTIL
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 239-541-9789