Provider Demographics
NPI:1093005753
Name:EMPIRE SPECIALTY PHARMACY LLC
Entity type:Organization
Organization Name:EMPIRE SPECIALTY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:NAGA LAXMI
Authorized Official - Last Name:CHEEDHELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-549-5005
Mailing Address - Street 1:1066 CLEARLAKE RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-6384
Mailing Address - Country:US
Mailing Address - Phone:321-549-5005
Mailing Address - Fax:321-549-6226
Practice Address - Street 1:378 N BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-7344
Practice Address - Country:US
Practice Address - Phone:321-549-5005
Practice Address - Fax:321-549-6226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X, 332B00000X
FLPH254063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003807200Medicaid
2130028OtherPK