Provider Demographics
NPI:1245272830
Name:FLORIDA DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACEUTICAL PROGRAM MGR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:D'AMICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-861-2932
Mailing Address - Street 1:PO BOX 2658
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34230-2658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7820 TAMIAMI TRL S
Practice Address - Street 2:BUILD B 2
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5120
Practice Address - Country:US
Practice Address - Phone:941-861-3352
Practice Address - Fax:941-861-3357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH173763336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022273900Medicaid
1090276OtherNCPDP PROVIDER IDENTIFICATION NUMBER