Healthcare Provider Details

I. General information

NPI: 1184063455
Provider Name (Legal Business Name): XTRA CARE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 US HIGHWAY 301 S STE 106
RIVERVIEW FL
33578-4324
US

IV. Provider business mailing address

6520 US HIGHWAY 301 S SUITE 106
RIVERVIEW FL
33578-4347
US

V. Phone/Fax

Practice location:
  • Phone: 813-280-0927
  • Fax: 813-677-4500
Mailing address:
  • Phone: 813-280-0927
  • Fax: 813-677-4500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH26712
License Number StateFL

VIII. Authorized Official

Name: MILDRED PETERSIDE
Title or Position: OWNER/PIC
Credential:
Phone: 813-598-0593