=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104302215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROHEALTH PHARMACY SOLUTIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2018
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 WINDERLEY PL STE 226
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-527-7940
-----------------------------------------------------
Fax | 407-670-0428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 WINDERLEY PL STE 228
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-527-7940
-----------------------------------------------------
Fax | 407-670-0428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KATHLEEN PATRICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-733-1910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH29369
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------