Basic Information
| Provider Information | |||||||||
| NPI: | 1457603078 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA HEALTH CARE PLAN INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FLORIDA HEALTH CARE PLANS PHARMACY MAIL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11696 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321201696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767126 | ||||||||
| FaxNumber: | 3866767165 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 RIDGEWOOD AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | HOLLY HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321172259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767126 | ||||||||
| FaxNumber: | 3866767165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2012 | ||||||||
| LastUpdateDate: | 03/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHANDEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3866767100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336M0003X | N | Suppliers | Pharmacy | Managed Care Organization Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336M0002X | PH23799 | FL | Y | Suppliers | Pharmacy | Mail Order Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2137305 | 01 | PK | OTHER |