MEDICARE: EXTENDED CARE PHARMACY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1088803	OTHER	FL	NCPDP

General Provider Information

NPI Number	:	1013913680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDED CARE PHARMACY, INC.

Provider Business Mailing Address
First Line	:	6400 CRILL AVE
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-3876
Country	:	US
Telephone Number	:	386-325-5505
Fax Number	:	386-328-9393

Provider Business Practice Location Address
First Line	:	6400 CRILL AVE
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-3876
Country	:	US
Telephone Number	:	386-325-5505
Fax Number	:	386-328-9393

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. MARK CASEY PHILLIPS
Credential	:
Telephone Number	:	386-325-5505

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	08/07/2012

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