Healthcare Provider Details

I. General information

NPI: 1255628095
Provider Name (Legal Business Name): INTERNAL MEDICINE ASSOCIATES OF LEE COUNTY PHARMACY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13813 METRO PKWY
FORT MYERS FL
33912-4343
US

IV. Provider business mailing address

13813 METRO PKWY
FORT MYERS FL
33912-4343
US

V. Phone/Fax

Practice location:
  • Phone: 239-938-1725
  • Fax: 205-970-6766
Mailing address:
  • Phone: 239-938-1725
  • Fax: 205-970-6766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH25555
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BARBARA WEITER
Title or Position: CONTROLLER
Credential:
Phone: 205-970-2263