Basic Information
| Provider Information | |||||||||
| NPI: | 1376616698 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SIMED HEALTH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIMEDHEALTH PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4343 W NEWBERRY RD | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522242450 | ||||||||
| FaxNumber: | 3522242451 | ||||||||
| Practice Location | |||||||||
| Address1: | 4343 W NEWBERRY RD | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522242450 | ||||||||
| FaxNumber: | 3522242451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUNCANSON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | MARTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3522242200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SIMED HEALTH LLC | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PH21312 | FL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 030860900 | 05 | FL | MEDICAID |