Provider Demographics
NPI:1033837307
Name:MY PHARMACY CRYSTAL RIVER, LLC
Entity type:Organization
Organization Name:MY PHARMACY CRYSTAL RIVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE & SALES
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-221-0658
Mailing Address - Street 1:2710 REW CIRCLE SUITE 200
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761
Mailing Address - Country:US
Mailing Address - Phone:407-654-5414
Mailing Address - Fax:407-654-9614
Practice Address - Street 1:927 N CITRUS AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428
Practice Address - Country:US
Practice Address - Phone:352-565-7342
Practice Address - Fax:352-565-5880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY PHARMACY CRYSTAL RIVER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty