MEDICARE: ARRIVA MEDICAL, 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
2	3336C0003X	Community/Retail Pharmacy	PH27239	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2164270	OTHER		PK

General Provider Information

NPI Number	:	1659821437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARRIVA MEDICAL, LLC

Provider Business Mailing Address
First Line	:	310 EAGLES LANDING DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-2999
Country	:	US
Telephone Number	:	866-336-4103
Fax Number	:	877-223-0483

Provider Business Practice Location Address
First Line	:	310 EAGLES LANDING DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-2999
Country	:	US
Telephone Number	:	866-336-4103
Fax Number	:	877-223-0483

Authorized Official
Title or Position	:	OPERATIONS VP
Name	:	TOM WALTERS
Credential	:
Telephone Number	:	800-700-4442

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	10/05/2016

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