1568148211 NPI number — OM RX PARTNERS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568148211 NPI number — OM RX PARTNERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OM RX PARTNERS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568148211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15835 SHADDOCK DR STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER GARDEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34787-5778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
862-203-8851
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15835 SHADDOCK DR STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER GARDEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34787-5778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
862-203-8851
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2023

Additional Information

Authorized Official

Authorized Official Last Name:
SRIDHARA
Authorized Official First Name:
SHASHANK
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY DEPARTMENT MANAGER
Authorized Official Telephone Number:
941-914-5045

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 121858300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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