MEDICARE: GRANDE PHARMACY LLC

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	3336C0003X	Community/Retail Pharmacy	PH23639	FL

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

General Provider Information

NPI Number	:	1396997300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANDE PHARMACY LLC

Provider Business Mailing Address
First Line	:	4015 E HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33610-3847
Country	:	US
Telephone Number	:	813-623-9911
Fax Number	:	813-623-9922

Provider Business Practice Location Address
First Line	:	4015 E HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33610-3847
Country	:	US
Telephone Number	:	813-623-9911
Fax Number	:	813-623-9922

Authorized Official
Title or Position	:	PHARMACIST
Name	:	QINGPING ZHANG
Credential	:
Telephone Number	:	813-623-9911

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	05/28/2010

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