Provider Demographics
NPI:1316958952
Name:EXP PHARMACY SVC OF FL LLC
Entity type:Organization
Organization Name:EXP PHARMACY SVC OF FL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GM
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDURE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:800-589-7255
Mailing Address - Street 1:8275 BRYAN DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33777-1324
Mailing Address - Country:US
Mailing Address - Phone:800-589-7255
Mailing Address - Fax:727-395-7892
Practice Address - Street 1:8275 BRYAN DAIRY RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33777-1324
Practice Address - Country:US
Practice Address - Phone:800-589-7255
Practice Address - Fax:727-395-7892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0003X
FLPH208403336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106251400Medicaid
1075058OtherNCPDP PROVIDER IDENTIFICATION NUMBER