Healthcare Provider Details

I. General information

NPI: 1669785168
Provider Name (Legal Business Name): MANGO PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11509 DR MARTIN LUTHER KING JR BLVD
MANGO FL
33550
US

IV. Provider business mailing address

11509 DR. MARTIN LUTHER KING JR. BLVD
MANGO FL
33550
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-2263
  • Fax: 813-662-2263
Mailing address:
  • Phone: 813-661-2263
  • Fax: 813-662-2263

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 NumberPH29956
License Number StateFL

VIII. Authorized Official

Name: ALPESH PATEL
Title or Position: OWNER
Credential:
Phone: 813-661-2263