Healthcare Provider Details

I. General information

NPI: 1396005344
Provider Name (Legal Business Name): KSP PHARMACY, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10549 N FLORIDA AVE SUITE A
TAMPA FL
33612-6707
US

IV. Provider business mailing address

10549 N FLORIDA AVE SUITE A
TAMPA FL
33612-6707
US

V. Phone/Fax

Practice location:
  • Phone: 813-936-9700
  • Fax: 813-936-9729
Mailing address:
  • Phone: 813-936-9700
  • Fax: 813-936-9729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JOHN CORREA
Title or Position: MEMBER
Credential:
Phone: 813-936-9700