Healthcare Provider Details

I. General information

NPI: 1740697895
Provider Name (Legal Business Name): MEDICOR HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 W WATERS AVE
TAMPA FL
33614-2713
US

IV. Provider business mailing address

3403 W WATERS AVE
TAMPA FL
33614-2713
US

V. Phone/Fax

Practice location:
  • Phone: 813-930-8000
  • Fax: 813-930-8026
Mailing address:
  • Phone: 813-930-8000
  • Fax: 813-930-8026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPH26927
License Number StateFL

VIII. Authorized Official

Name: DWIGHT COLSTON
Title or Position: PHARMACY MANAGER
Credential:
Phone: 813-930-8000