MEDICARE: COASTAL SPECIALTY 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	333600000X	Pharmacy

General Provider Information

NPI Number	:	1598009573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL SPECIALTY PHARMACY LLC

Provider Business Mailing Address
First Line	:	2050 W COUNTY HIGHWAY 30A
Second Line	:	M1-106
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-0187
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2050 W COUNTY HIGHWAY 30A
Second Line	:	M1-106
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-0187
Country	:	US
Telephone Number	:	850-622-3315
Fax Number	:

Authorized Official
Title or Position	:	MGMR
Name	:	JOAN ELLISON
Credential	:	PHARMD
Telephone Number	:	850-622-3313

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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Directions to “COASTAL SPECIALTY PHARMACY LLC ” Practice Location

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