Healthcare Provider Details

I. General information

NPI: 1942374012
Provider Name (Legal Business Name): MEDIPHARM-RX,INC.(SPECIAL CLOSED SYSTEM)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 N CLARK AVE
TAMPA FL
33614-7038
US

IV. Provider business mailing address

4607 N CLARK AVE
TAMPA FL
33614-7038
US

V. Phone/Fax

Practice location:
  • Phone: 813-876-0881
  • Fax: 813-876-0883
Mailing address:
  • Phone: 813-876-0881
  • Fax: 813-876-0883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH21000
License Number StateFL

VIII. Authorized Official

Name: MRS. DIANE L ELLIS
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 813-876-0881