Healthcare Provider Details

I. General information

NPI: 1235444183
Provider Name (Legal Business Name): COCOA BEACH DISCOUNT PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 W COCOA BEACH CSWY
COCOA BEACH FL
32931-3529
US

IV. Provider business mailing address

291 W COCOA BEACH CSWY
COCOA BEACH FL
32931-3529
US

V. Phone/Fax

Practice location:
  • Phone: 321-799-2030
  • Fax: 321-799-2050
Mailing address:
  • Phone: 321-799-2030
  • Fax: 321-799-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH24812
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier002760200
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
Identifier5701354
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: HETALBEN PATEL
Title or Position: PHARMACY MANAGER
Credential:
Phone: 321-799-2030