MEDICARE: ST. PHILLO 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	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1871139774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. PHILLO LLC

Provider Business Mailing Address
First Line	:	4127 MARINER BLVD
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34609-2469
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4127 MARINER BLVD
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34609-2469
Country	:	US
Telephone Number	:	352-556-2516
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST/OWNER
Name	:	MICHAEL SHAKER
Credential	:
Telephone Number	:	352-556-2516

Provider Enumeration Date	:	11/26/2019
Last Update Date	:	11/16/2022

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