Healthcare Provider Details

I. General information

NPI: 1144541830
Provider Name (Legal Business Name): MALABAR PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MALABAR RD SE STE 1
PALM BAY FL
32907-3252
US

IV. Provider business mailing address

930 MALABAR RD SE STE 1
PALM BAY FL
32907-3252
US

V. Phone/Fax

Practice location:
  • Phone: 321-775-0911
  • Fax: 321-775-0912
Mailing address:
  • Phone: 321-775-0911
  • Fax: 321-775-0912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH24682
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH24682
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH24682
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPH24682
License Number StateFL

VIII. Authorized Official

Name: MR. ANKUR SHAH
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 321-432-0675