Healthcare Provider Details

I. General information

NPI: 1336326784
Provider Name (Legal Business Name): ONE SOURCE PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6404 OLD WINTER GARDEN RD STE 100
ORLANDO FL
32835
US

IV. Provider business mailing address

6404 OLD WINTER GARDEN RD SUITE 250
ORLANDO FL
32835
US

V. Phone/Fax

Practice location:
  • Phone: 877-490-8987
  • Fax: 877-490-1060
Mailing address:
  • Phone: 877-490-8987
  • Fax: 877-490-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH25399
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberPENDING
License Number StateFL

VIII. Authorized Official

Name: MR. INDRAJIT VYAS
Title or Position: OWNER/ MGR
Credential:
Phone: 877-490-8987