Provider Demographics
NPI:1396997300
Name:GRANDE PHARMACY LLC
Entity type:Organization
Organization Name:GRANDE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:QINGPING
Authorized Official - Middle Name:
Authorized Official - Last Name:ZHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-623-9911
Mailing Address - Street 1:4015 E HILLSBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-3847
Mailing Address - Country:US
Mailing Address - Phone:813-623-9911
Mailing Address - Fax:813-623-9922
Practice Address - Street 1:4015 E HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-3847
Practice Address - Country:US
Practice Address - Phone:813-623-9911
Practice Address - Fax:813-623-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH236393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000751400Medicaid
FL6317050001Medicare NSC