MEDICARE: CARL D ACQUAVIVA

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PH10316	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1038036	OTHER	NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013928514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARL D ACQUAVIVA

Provider Business Mailing Address
First Line	:	1555 PORT MALABAR BLVD NE
Second Line	:	UNIT 101
City	:	PALM BAY
State	:	FL
Zip	:	32905-5407
Country	:	US
Telephone Number	:	321-725-7188
Fax Number	:	321-728-1333

Provider Business Practice Location Address
First Line	:	1555 PORT MALABAR BLVD NE
Second Line	:	UNIT 101
City	:	PALM BAY
State	:	FL
Zip	:	32905-5407
Country	:	US
Telephone Number	:	321-725-7188
Fax Number	:	321-728-1333

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	CARL D ACQUAVIVA
Credential	:	RPH
Telephone Number	:	321-725-7188

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	04/02/2009

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1528203775 — CARL D ACQUAVIVA
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1780970673 — CARL D ACQUAVIVA
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Directions to “CARL D ACQUAVIVA ” Practice Location

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