Provider Demographics
NPI:1093222622
Name:PHARMACY AT ABACOA INC
Entity type:Organization
Organization Name:PHARMACY AT ABACOA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-630-3770
Mailing Address - Street 1:PO BOX 912
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468
Mailing Address - Country:US
Mailing Address - Phone:855-349-6800
Mailing Address - Fax:561-630-3771
Practice Address - Street 1:1155 MAIN ST
Practice Address - Street 2:UNIT 109
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5263
Practice Address - Country:US
Practice Address - Phone:561-630-3770
Practice Address - Fax:561-630-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH308193336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175233OtherPK
FL022716900Medicaid