Provider Demographics
NPI:1154101731
Name:LEGACY PHARMACY OC LLC
Entity type:Organization
Organization Name:LEGACY PHARMACY OC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIPTIBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-218-4993
Mailing Address - Street 1:921 TOWN CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8266
Mailing Address - Country:US
Mailing Address - Phone:386-218-4993
Mailing Address - Fax:386-218-4913
Practice Address - Street 1:921 TOWN CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8266
Practice Address - Country:US
Practice Address - Phone:386-218-4993
Practice Address - Fax:386-218-4913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-02
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy