Healthcare Provider Details

I. General information

NPI: 1346647005
Provider Name (Legal Business Name): MEDOZ PHARMACY OF POLK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40230 US HIGHWAY 27 N SUITE 100-110
DAVENPORT FL
33837-2636
US

IV. Provider business mailing address

40230 US HIGHWAY 27 N SUITE 100-110
DAVENPORT FL
33837-2636
US

V. Phone/Fax

Practice location:
  • Phone: 855-633-6948
  • Fax: 844-329-6348
Mailing address:
  • Phone: 855-633-6948
  • Fax: 844-329-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPH28722
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH28722
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPS28722
License Number StateFL
# 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: ABRAHAM MERMELSTEIN
Title or Position: MANAGING MEMBER
Credential:
Phone: 732-267-7782