=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154773950
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2016
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 917 MAR WALT DRIVE SUITE D
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-312-3570
-----------------------------------------------------
Fax | 850-312-3090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 W. NORTHWEST HWY SUITE 100
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-572-0009
-----------------------------------------------------
Fax | 817-572-0221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT OF OPERATIONS
-----------------------------------------------------
Name | MR. ERIC SQUATRITO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-977-8498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PH30219
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------