Healthcare Provider Details

I. General information

NPI: 1629398003
Provider Name (Legal Business Name): ANNALICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6506 EMBASSY BLVD
PORT RICHEY FL
34668-4734
US

IV. Provider business mailing address

6506 EMBASSY BLVD
PORT RICHEY FL
34668-4734
US

V. Phone/Fax

Practice location:
  • Phone: 727-848-9400
  • Fax:
Mailing address:
  • Phone: 727-848-9400
  • Fax: 727-848-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH24598
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: NELSON OHIHOIN
Title or Position: PRESIDENT
Credential:
Phone: 727-534-1318