=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609111764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAB PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2012
-----------------------------------------------------
Last Update Date | 09/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 1ST ST S SUITE 1
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-4307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-229-5974
-----------------------------------------------------
Fax | 863-229-5975
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 1ST ST S SUITE 1
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-4307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-229-5974
-----------------------------------------------------
Fax | 863-229-5975
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | BHARATH JANNU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-229-5974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH26527
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------