Provider Demographics
NPI:1427307461
Name:INNOVATIVERX GULF COAST PHARMACY INC
Entity type:Organization
Organization Name:INNOVATIVERX GULF COAST PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MACNEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-631-9140
Mailing Address - Street 1:8222 118TH AVE
Mailing Address - Street 2:SUITE 605
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-5053
Mailing Address - Country:US
Mailing Address - Phone:239-324-9619
Mailing Address - Fax:239-280-1226
Practice Address - Street 1:1035 COLLIER CENTER WAY STE 2
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-8474
Practice Address - Country:US
Practice Address - Phone:239-324-9619
Practice Address - Fax:239-280-1226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH263483336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136766OtherPK