Provider Demographics
NPI:1063572295
Name:OPTUMCARE FLORIDA, LLC
Entity type:Organization
Organization Name:OPTUMCARE FLORIDA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-205-6262
Mailing Address - Street 1:10051 5TH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2299
Mailing Address - Country:US
Mailing Address - Phone:727-849-9373
Mailing Address - Fax:727-841-0497
Practice Address - Street 1:4757 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4945
Practice Address - Country:US
Practice Address - Phone:727-849-9373
Practice Address - Fax:727-841-0497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0003X
FLPH186033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030843900Medicaid
FL4399230001Medicaid
2014572OtherPK
FL4399230001Medicaid