Basic Information
| Provider Information | |||||||||
| NPI: | 1427203876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TLCRX1 LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FRIENDS PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S HARBOUR ISLAND BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336025925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525725457 | ||||||||
| FaxNumber: | 8009859168 | ||||||||
| Practice Location | |||||||||
| Address1: | 1714 SW 17TH ST | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344711227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522749455 | ||||||||
| FaxNumber: | 8774050955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2008 | ||||||||
| LastUpdateDate: | 08/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUNDARAMOORTHY | ||||||||
| AuthorizedOfficialFirstName: | SRIRAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3526227000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PH23731 | FL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 000702300 | 05 | FL | MEDICAID | 2118172 | 01 | PK | OTHER |