Healthcare Provider Details

I. General information

NPI: 1871325241
Provider Name (Legal Business Name): UMATILLA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N CENTRAL AVE
UMATILLA FL
32784-8655
US

IV. Provider business mailing address

PO BOX 1250
SAN ANTONIO FL
33576-1250
US

V. Phone/Fax

Practice location:
  • Phone: 352-669-1166
  • Fax: 352-669-8866
Mailing address:
  • Phone: 352-409-1061
  • Fax:

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: SHANNON CORKREAN
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 352-409-1061