Healthcare Provider Details

I. General information

NPI: 1467830638
Provider Name (Legal Business Name): MIDWAY SPECIALTY CARE RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 S US HIGHWAY I
FORT PIERCE FL
34982-6381
US

IV. Provider business mailing address

356 E MIDWAY ROAD
FORT PIERCE FL
34982-7148
US

V. Phone/Fax

Practice location:
  • Phone: 772-464-9746
  • Fax: 772-464-9750
Mailing address:
  • Phone: 772-464-9746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberPH29049
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SUZETTE WOOD
Title or Position: PHARMACY DIRECTOR
Credential: PHARMD
Phone: 772-465-4442