MEDICARE: CHARLES PHARMACY INC

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	PH1016	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1031121	OTHER		OTHER ID NUMBER
2	1031121	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1942346556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES PHARMACY INC

Provider Business Mailing Address
First Line	:	5987 BERRYHILL RD
Second Line	:
City	:	MILTON
State	:	FL
Zip	:	32570-4043
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5987 BERRYHILL RD
Second Line	:
City	:	MILTON
State	:	FL
Zip	:	32570-4043
Country	:	US
Telephone Number	:	850-623-6008
Fax Number	:	850-623-4522

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES VANLANDINGHAM
Credential	:
Telephone Number	:	850-623-6008

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	09/12/2007

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Directions to “CHARLES PHARMACY INC ” Practice Location

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