Provider Demographics
NPI:1861532145
Name:FISHER PHARMACY, INC
Entity type:Organization
Organization Name:FISHER PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ROEHM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:850-892-5612
Mailing Address - Street 1:688 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-2596
Mailing Address - Country:US
Mailing Address - Phone:850-892-5612
Mailing Address - Fax:850-892-5089
Practice Address - Street 1:688 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-2596
Practice Address - Country:US
Practice Address - Phone:850-892-5612
Practice Address - Fax:850-892-5089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FLPH0001853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104725600Medicaid
FL104725601OtherMEDICAID-DME
FL4098560001Medicare ID - Type Unspecified