Healthcare Provider Details

I. General information

NPI: 1366416448
Provider Name (Legal Business Name): PACIFICO NATIONAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 ELIZABETH ST STE J
MELBOURNE FL
32901-3000
US

IV. Provider business mailing address

1515 ELIZABETH ST STE J
MELBOURNE FL
32901-3000
US

V. Phone/Fax

Practice location:
  • Phone: 321-872-0723
  • Fax: 321-872-0721
Mailing address:
  • Phone: 321-872-0723
  • Fax: 321-872-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number16452MS
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number5301008923
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH27532
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberFL1446
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberNRX1701137
License Number StateDC
# 6
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberA9-0001042
License Number StateDE
# 7
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number3942
License Number StateIA
# 8
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberP03052
License Number StateMD
# 9
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number64000903A
License Number StateIN
# 10
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number22-02899
License Number StateKS
# 11
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHNR 000556
License Number StateGA
# 12
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number006292
License Number StateLA
# 13
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number054.016601
License Number StateIL
# 14
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPMP-1330
License Number StateHI
# 15
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateAL

VIII. Authorized Official

Name: MARK SANGREE
Title or Position: PRES
Credential:
Phone: 321-872-0723