Healthcare Provider Details

I. General information

NPI: 1578715215
Provider Name (Legal Business Name): HEPZIBAH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10802 MAIN ST STE A
THONOTOSASSA FL
33592-2840
US

IV. Provider business mailing address

3500 E FLETCHER AVE
TAMPA FL
33613-4708
US

V. Phone/Fax

Practice location:
  • Phone: 813-413-8242
  • Fax: 813-413-8302
Mailing address:
  • Phone: 813-413-8242
  • Fax: 813-413-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH23546
License Number StateFL

VIII. Authorized Official

Name: JACK DIAMOND
Title or Position: OWNER, VP, AO
Credential:
Phone: 813-484-8611