MEDICARE: POLK CITY 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	333600000X	Pharmacy	PH21515	FL
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053987	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1417040486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLK CITY PHARMACY INC

Provider Business Mailing Address
First Line	:	108 N COMMONWEALTH AVE
Second Line	:
City	:	POLK CITY
State	:	FL
Zip	:	33868-9506
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 N COMMONWEALTH AVE
Second Line	:
City	:	POLK CITY
State	:	FL
Zip	:	33868-9506
Country	:	US
Telephone Number	:	863-984-3427
Fax Number	:	863-984-9631

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	JACQUELINE A FUTCH
Credential	:	PHARMD
Telephone Number	:	863-984-9631

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	03/07/2023

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Directions to “POLK CITY PHARMACY INC ” Practice Location

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