Provider Demographics
NPI:1053729418
Name:NIMOH PHARMACY AND COMPOUNDING LLC
Entity type:Organization
Organization Name:NIMOH PHARMACY AND COMPOUNDING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:P.I.C / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DADDY
Authorized Official - Middle Name:NIMOH
Authorized Official - Last Name:BOATENG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:352-437-5985
Mailing Address - Street 1:12878 US HIGHWAY 301
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-5801
Mailing Address - Country:US
Mailing Address - Phone:352-437-5985
Mailing Address - Fax:
Practice Address - Street 1:12878 US HIGHWAY 301
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5801
Practice Address - Country:US
Practice Address - Phone:352-437-5985
Practice Address - Fax:352-437-5986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
FLPH283473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012884100Medicaid
2147069OtherPK
FL012884100Medicaid