Provider Demographics
NPI:1548202211
Name:OCOEE PROFESSIONAL PHARMACY LLC
Entity type:Organization
Organization Name:OCOEE PROFESSIONAL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-667-8532
Mailing Address - Street 1:2401 N OCOEE ST
Mailing Address - Street 2:STE A
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3853
Mailing Address - Country:US
Mailing Address - Phone:423-472-3561
Mailing Address - Fax:423-472-5329
Practice Address - Street 1:2401 N OCOEE ST STE A
Practice Address - Street 2:STE A
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3853
Practice Address - Country:US
Practice Address - Phone:423-472-3561
Practice Address - Fax:423-472-5329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 333600000X
TN39223336L0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454645Medicaid
2093986OtherPK
4436843OtherNCPDP PROVIDER IDENTIFICATION NUMBER