MEDICARE: MAGNOLIA 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
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PH26768	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2139695	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841532108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA PHARMACY LLC

Provider Business Mailing Address
First Line	:	12525 CURLEY ST
Second Line	:
City	:	SAN ANTONIO
State	:	FL
Zip	:	33576-7094
Country	:	US
Telephone Number	:	352-588-3330
Fax Number	:	352-588-3337

Provider Business Practice Location Address
First Line	:	12525 CURLEY ST
Second Line	:
City	:	SAN ANTONIO
State	:	FL
Zip	:	33576-7094
Country	:	US
Telephone Number	:	352-588-3330
Fax Number	:	352-588-3337

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	SHANNON CORKREAN
Credential	:
Telephone Number	:	352-409-1061

Provider Enumeration Date	:	03/25/2013
Last Update Date	:	07/13/2023

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Directions to “MAGNOLIA PHARMACY LLC ” Practice Location

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