{
"Npi": {
"NPI": "1962809475",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MEDOZ PHARMACY OF POLK INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "40230 US HIGHWAY 27",
"SecondLineMailingAddress": "#100-110",
"MailingAddressCityName": "DAVENPORT",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33837",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "855-633-6948",
"MailingAddressFaxNumber": "844-329-6348",
"FirstLinePracticeLocationAddress": "40230 US HIGHWAY 27",
"SecondLinePracticeLocationAddress": "#100-110",
"PracticeLocationAddressCityName": "DAVENPORT",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "33837",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "855-633-6948",
"PracticeLocationAddressFaxNumber": "844-329-6348",
"EnumerationDate": "11/26/2014",
"LastUpdateDate": "11/26/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PALAN",
"AuthorizedOfficialFirstName": "TUSHAR",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "MISS",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "855-633-6948",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0004X",
"TaxonomyName": "Compounding Pharmacy",
"LicenseNumber": "PH28725",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}