=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891728580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METCARE RX ORMOND BEACH PHARMACEUTICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 W GRANADA BLVD SUITE 5
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-8156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-673-2210
-----------------------------------------------------
Fax | 386-676-9223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 W GRANADA BLVD SUITE 5
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-8156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-673-2210
-----------------------------------------------------
Fax | 386-676-9223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VP CORPORATE REVENUE
-----------------------------------------------------
Name | GINA HUNT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-653-1040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH20116
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------