MEDICARE: ANNALICE 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
2	333600000X	Pharmacy	PH24598	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5700807	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1629398003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANNALICE LLC

Provider Business Mailing Address
First Line	:	6506 EMBASSY BLVD
Second Line	:
City	:	PORT RICHEY
State	:	FL
Zip	:	34668-4734
Country	:	US
Telephone Number	:	727-848-9400
Fax Number	:	727-848-9401

Provider Business Practice Location Address
First Line	:	6506 EMBASSY BLVD
Second Line	:
City	:	PORT RICHEY
State	:	FL
Zip	:	34668-4734
Country	:	US
Telephone Number	:	727-848-9400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NELSON OHIHOIN
Credential	:
Telephone Number	:	727-534-1318

Provider Enumeration Date	:	06/08/2010
Last Update Date	:	10/28/2010

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Directions to “ANNALICE LLC ” Practice Location

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