Healthcare Provider Details

I. General information

NPI: 1093005753
Provider Name (Legal Business Name): EMPIRE SPECIALTY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

378 N BABCOCK ST
MELBOURNE FL
32935-7344
US

IV. Provider business mailing address

1066 CLEARLAKE RD
COCOA FL
32922-6384
US

V. Phone/Fax

Practice location:
  • Phone: 321-549-5005
  • Fax: 321-549-6226
Mailing address:
  • Phone: 321-549-5005
  • Fax: 321-549-6226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
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 NumberPH25406
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: VENKATA NAGA LAXMI CHEEDHELLA
Title or Position: PRESIDENT
Credential:
Phone: 321-549-5005