{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MAGNOLIA PHARMACY LLC",
"LastName": null,
"FirstName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "12525 CURLEY ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SAN ANTONIO",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33576-7094",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "352-588-3330",
"MailingAddressFaxNumber": "352-588-3337",
"FirstLinePracticeLocationAddress": "12525 CURLEY ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SAN ANTONIO",
"PracticeLocationAddressStateName": "FL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "352-588-3330",
"PracticeLocationAddressFaxNumber": "352-588-3337",
"EnumerationDate": "03/25/2013",
"LastUpdateDate": "07/13/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CORKREAN",
"AuthorizedOfficialFirstName": "SHANNON",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER/PHARMACIST",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "352-409-1061",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "333600000X",
"TaxonomyName": "Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "3336C0004X",
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},
{
"TaxonomyCode": "3336C0003X",
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"LicenseNumber": "PH26768",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}