Basic Information
| Provider Information | |||||||||
| NPI: | 1942584057 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAVKOO INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RAVKOO PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 301 HAVENDALE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUBURNDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8638755700 | ||||||||
| FaxNumber: | 8638755619 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 HAVENDALE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUBURNDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338234513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8638755700 | ||||||||
| FaxNumber: | 8638755619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2011 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | ALPESH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8133042221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0003X | PH25675 | FL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 7100391660 | 05 | KY | MEDICAID | 2132075 | 01 | PK | OTHER | 150419 | 05 | OH | MEDICAID | 201342200 A | 05 | IN | MEDICAID | 00416640 | 05 | FL | MEDICAID |