Provider Demographics
NPI:1053528448
Name:GUARDIAN PHARMACY OF DAYTONA, LLC
Entity type:Organization
Organization Name:GUARDIAN PHARMACY OF DAYTONA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-615-1925
Mailing Address - Street 1:GUARDIAN PHARMACY OF DAYTONA DEPT 2360
Mailing Address - Street 2:P.O. BOX 11407
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2360
Mailing Address - Country:US
Mailing Address - Phone:404-810-0089
Mailing Address - Fax:404-810-0094
Practice Address - Street 1:10 AVIATOR WAY
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-2983
Practice Address - Country:US
Practice Address - Phone:386-615-1925
Practice Address - Fax:386-615-1996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH226453336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032055200Medicaid
FL032055200Medicaid