Provider Demographics
NPI:1053356113
Name:HILLMOOR PLAZA PHARMACY INC
Entity type:Organization
Organization Name:HILLMOOR PLAZA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:772-468-0074
Mailing Address - Street 1:9312 FOREST HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9312 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33411-6577
Practice Address - Country:US
Practice Address - Phone:561-753-6768
Practice Address - Fax:561-753-6763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH131123336C0003X
3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102866900Medicaid
FL102866902Medicaid
1075022OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL102866901Medicaid
FL102866901Medicaid