Provider Demographics
NPI:1962809475
Name:MEDOZ PHARMACY OF POLK INC
Entity type:Organization
Organization Name:MEDOZ PHARMACY OF POLK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:TUSHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-633-6948
Mailing Address - Street 1:40230 US HIGHWAY 27
Mailing Address - Street 2:#100-110
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837
Mailing Address - Country:US
Mailing Address - Phone:855-633-6948
Mailing Address - Fax:844-329-6348
Practice Address - Street 1:40230 US HIGHWAY 27
Practice Address - Street 2:#100-110
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837
Practice Address - Country:US
Practice Address - Phone:855-633-6948
Practice Address - Fax:844-329-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH287253336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH28725OtherPHARMACY