Healthcare Provider Details

I. General information

NPI: 1467752691
Provider Name (Legal Business Name): BREVARD PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 N US HIGHWAY 1
COCOA FL
32927-4926
US

IV. Provider business mailing address

6250 N US HIGHWAY 1
COCOA FL
32927-4926
US

V. Phone/Fax

Practice location:
  • Phone: 321-305-6975
  • Fax: 321-305-6978
Mailing address:
  • Phone: 321-305-6975
  • Fax: 321-305-6978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
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 NumberPH30509
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHANDRIKABEN PATEL
Title or Position: OWNER
Credential: RPH
Phone: 407-488-6851