Healthcare Provider Details

I. General information

NPI: 1346016052
Provider Name (Legal Business Name): PIONEER RX PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

494 PONDEROSA DR
SAINT CLOUD FL
34769-1656
US

IV. Provider business mailing address

494 PONDEROSA DR
SAINT CLOUD FL
34769-1656
US

V. Phone/Fax

Practice location:
  • Phone: 407-593-1600
  • Fax:
Mailing address:
  • Phone: 407-593-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SAJI THOMAS
Title or Position: MANGER
Credential:
Phone: 407-968-4218