MEDICARE: PRIME PHARMACY SERVICES, 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	PH23013	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1030129	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1467632224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME PHARMACY SERVICES, LLC

Provider Business Mailing Address
First Line	:	1861 BANKS RD
Second Line	:	STE A
City	:	MARGATE
State	:	FL
Zip	:	33063-7707
Country	:	US
Telephone Number	:	954-977-7875
Fax Number	:	965-977-7871

Provider Business Practice Location Address
First Line	:	2427 PORTER LAKE DR STE 109A
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34240-8853
Country	:	US
Telephone Number	:	941-378-2607
Fax Number	:	941-378-2699

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARK ERBLAT
Credential	:
Telephone Number	:	941-378-9004

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	02/26/2013

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