Healthcare Provider Details

I. General information

NPI: 1366868911
Provider Name (Legal Business Name): GREENWOOD HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 W LAKE MARY BLVD UNIT 127
LAKE MARY FL
32746-6168
US

IV. Provider business mailing address

3801 W LAKE MARY BLVD UNIT 127
LAKE MARY FL
32746-6168
US

V. Phone/Fax

Practice location:
  • Phone: 407-915-6505
  • Fax:
Mailing address:
  • Phone: 407-915-6505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH27610
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH27610
License Number StateFL

VIII. Authorized Official

Name: MR. ANDREW KIMMEL
Title or Position: MANAGER
Credential: PHARMACIST
Phone: 407-915-6505