Healthcare Provider Details

I. General information

NPI: 1023599321
Provider Name (Legal Business Name): BAYSIDE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 1ST ST S STE 106
WINTER HAVEN FL
33880-3266
US

IV. Provider business mailing address

205 1ST ST S STE 106
WINTER HAVEN FL
33880-3266
US

V. Phone/Fax

Practice location:
  • Phone: 863-377-4774
  • Fax: 863-377-4744
Mailing address:
  • Phone: 863-377-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH31592
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PROF. CHIRANJIVI B JANNU
Title or Position: DIRECTOR OF PHARMACY
Credential: R.PH
Phone: 646-673-0044