Basic Information
| Provider Information | |||||||||
| NPI: | 1013237668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMMOKALEE PHARMACY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PIPER DRUGS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2812 W. MLK JR BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133283970 | ||||||||
| FaxNumber: | 2396586127 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 PIPER BLVD | ||||||||
| Address2: | UNIT 12 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396586123 | ||||||||
| FaxNumber: | 2396586127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2010 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | HARKIKKUMAR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8133283970 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | 30304 | FL | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 018774100 | 05 | FL | MEDICAID | 2162462 | 01 | PK | OTHER |