Healthcare Provider Details

I. General information

NPI: 1104270404
Provider Name (Legal Business Name): FILL RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

776 DELTONA BLVD
DELTONA FL
32725-7107
US

IV. Provider business mailing address

776 DELTONA BLVD
DELTONA FL
32725-7107
US

V. Phone/Fax

Practice location:
  • Phone: 386-259-4074
  • Fax: 386-259-9037
Mailing address:
  • Phone: 386-259-4074
  • Fax: 386-259-9037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH29977
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JIGAR PATEL
Title or Position: CO-OWNER
Credential:
Phone: 386-259-4074