Provider Demographics
NPI:1861942740
Name:EXTRA CARE CITY PHARMACY LLC
Entity type:Organization
Organization Name:EXTRA CARE CITY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:UCHENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBIDIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-816-5252
Mailing Address - Street 1:1000 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8140
Mailing Address - Country:US
Mailing Address - Phone:716-816-5252
Mailing Address - Fax:407-542-5164
Practice Address - Street 1:1000 EXECUTIVE DR STE 2
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8140
Practice Address - Country:US
Practice Address - Phone:407-890-9241
Practice Address - Fax:407-542-5164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH303893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164639OtherPK
FL020010800Medicaid