Healthcare Provider Details

I. General information

NPI: 1932420247
Provider Name (Legal Business Name): CAPRICORN HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 E HILLSBOROUGH AVE STE D&E SUITE D & E
TAMPA FL
33610-5200
US

IV. Provider business mailing address

4505 E HILLSBOROUGH AVE STE D&E SUITE D & E
TAMPA FL
33610-5200
US

V. Phone/Fax

Practice location:
  • Phone: 813-628-8400
  • Fax: 813-628-8484
Mailing address:
  • Phone: 813-628-8400
  • Fax: 813-628-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH24697
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ADENIKE NIKI GANSALLO
Title or Position: PRESIDENT
Credential: BSC PHARMACY
Phone: 813-628-8400