MEDICARE: FT MEADE COMMUNITY 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
2	3336C0003X	Community/Retail Pharmacy	PH21788	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1017525	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1548275159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FT MEADE COMMUNITY PHARMACY INC

Provider Business Mailing Address
First Line	:	107 W BROADWAY ST STE B
Second Line	:
City	:	FORT MEADE
State	:	FL
Zip	:	33841-3300
Country	:	US
Telephone Number	:	863-285-9285
Fax Number	:	863-285-9982

Provider Business Practice Location Address
First Line	:	107 W BROADWAY ST STE B
Second Line	:
City	:	FORT MEADE
State	:	FL
Zip	:	33841-3300
Country	:	US
Telephone Number	:	863-285-9285
Fax Number	:	863-285-9982

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN JOHNSON
Credential	:	RPH
Telephone Number	:	863-285-9285

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	06/30/2010

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