Basic Information
| Provider Information | |||||||||
| NPI: | 1003991399 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKSVILLE DRUGS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BROOKSVILLE DRUGS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 80 PONCE DE LEON BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527964975 | ||||||||
| FaxNumber: | 3527338307 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 PONCE DE LEON BLVD. | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527964975 | ||||||||
| FaxNumber: | 3527998307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | ALPESH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8133042221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PH6749 | FL | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0003X | FL6749 | FL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 003463800 | 05 | FL | MEDICAID | 1033202 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |