Healthcare Provider Details

I. General information

NPI: 1053716936
Provider Name (Legal Business Name): ADVANCED RX DERM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 GULF BLVD
ST PETE BEACH FL
33706-1821
US

IV. Provider business mailing address

PO BOX 1730
LUTZ FL
33548-1730
US

V. Phone/Fax

Practice location:
  • Phone: 407-753-6310
  • Fax: 844-566-0501
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH28614
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PARVINDER S KAINTH
Title or Position: MANAGER
Credential:
Phone: 407-753-6310