Healthcare Provider Details

I. General information

NPI: 1619344777
Provider Name (Legal Business Name): MT. DORA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461-463 PLAZA DRIVE
EUSTIS FL
32726
US

IV. Provider business mailing address

2722 W. OLD US HWY 441
MOUNT DORA FL
32757
US

V. Phone/Fax

Practice location:
  • Phone: 352-729-6557
  • Fax: 352-385-7412
Mailing address:
  • Phone: 352-729-6557
  • Fax: 352-385-7412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
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 NumberPH29311
License Number StateFL

VIII. Authorized Official

Name: ALPESH PATEL
Title or Position: OWNER
Credential:
Phone: 813-304-2221