Basic Information
| Provider Information | |||||||||
| NPI: | 1164546875 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA HEALTH CARE PLAN, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FLORIDA HEALTH CARE PLAN PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 RIDGEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321172320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767173 | ||||||||
| FaxNumber: | 3866767165 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 DUNLAWTON AVE | ||||||||
| Address2: | STE 150 | ||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321274239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867670563 | ||||||||
| FaxNumber: | 3867617095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | SCHANDEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3866767100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336M0003X | PH23783 | FL | Y | Suppliers | Pharmacy | Managed Care Organization Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2004150 | 01 | PK | OTHER |