Provider Demographics
NPI:1851438527
Name:DELTONA MEDICAL ARTS PHARMACY INC
Entity type:Organization
Organization Name:DELTONA MEDICAL ARTS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:386-774-7933
Mailing Address - Street 1:921 TOWN CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8311
Mailing Address - Country:US
Mailing Address - Phone:386-774-7933
Mailing Address - Fax:386-774-7944
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:386-774-7933
Practice Address - Fax:386-774-7944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 332B00000X, 333600000X
FLPH107853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102109502Medicaid
FL102109500Medicaid
2008786OtherPK
FL102109500Medicaid