=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588944060
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENC MITA PHARM D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2011
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2295 E BAY DR
-----------------------------------------------------
City | LARGO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33771-2324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-585-9810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11231 COTTONWOOD DR UNIT C
-----------------------------------------------------
City | PALOS HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60465-2537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-935-8177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS44730
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051292841
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------