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General NPI Number Information
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NPI Number | 1568891125
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Entity Type | Organization
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Legal Business Name | PROVIDENCE PHARMACY LLC
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Dates
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Enumeration Date | 11/04/2013
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Last Update Date | 01/20/2017
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Provider Practice Location Address
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Address Line | 5515 US HIGHWAY 98 N STE 1
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City | LAKELAND
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State | FL
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Zip | 33809-3133
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Country | US
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Telephone | 863-937-8092
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Fax | 863-937-8093
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Provider Business Mailing Address
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Address Line | 7774 CANTERBURY CIR
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City | LAKELAND
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State | FL
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Zip | 33810-3408
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Country | US
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Telephone | 863-255-8777
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Fax |
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Authorized Official
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Title or Position | PHARMACIST
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Name | EDWIN ASANTE
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Credential |
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Telephone | 863-937-8092
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH27055
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License Number State | FL
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