Healthcare Provider Details

I. General information

NPI: 1346554433
Provider Name (Legal Business Name): 1ST COMMUNITY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 OLD WINTER GARDEN RD
OCOEE FL
34761-2995
US

IV. Provider business mailing address

2775 OLD WINTER GARDEN RD
OCOEE FL
34761-2995
US

V. Phone/Fax

Practice location:
  • Phone: 407-656-0641
  • Fax: 407-656-0643
Mailing address:
  • Phone: 407-656-0641
  • Fax: 407-656-0643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
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 NumberPH24784
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier002601000
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
Identifier2126064
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: J C
Title or Position: PHARMACY MANAGER
Credential:
Phone: 407-656-0641