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General NPI Number Information
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NPI Number | 1568188936
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Entity Type | Organization
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Legal Business Name | PINE BROOK PHARMACY LTC LLC
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Dates
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Enumeration Date | 10/17/2022
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Last Update Date | 10/17/2022
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Provider Practice Location Address
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Address Line | 10507 SPRING HILL DR STE 101
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City | SPRING HILL
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State | FL
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Zip | 34608-5047
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Country | US
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Telephone | 813-454-3500
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Fax |
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Provider Business Mailing Address
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Address Line | 19107 HARBOR COVE CT
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City | LUTZ
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State | FL
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Zip | 33558-9702
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Country | US
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Telephone | 813-454-3500
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GAUTAM THAKKAR
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Credential | RPH
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Telephone | 813-454-3500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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