=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053834267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPNN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2017
-----------------------------------------------------
Last Update Date | 08/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5429 LITTLE RD
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-507-0888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5429 LITTLE RD
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34655-1107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-372-5600
-----------------------------------------------------
Fax | 727-372-5603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHADY BASTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-372-5600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH30846
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------