Provider Demographics
NPI:1447302963
Name:MATRIX PHARMACY, LLC
Entity type:Organization
Organization Name:MATRIX PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:P (PHIL)
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:813-514-0494
Mailing Address - Street 1:PO BOX 274070
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-4070
Mailing Address - Country:US
Mailing Address - Phone:800-784-0882
Mailing Address - Fax:
Practice Address - Street 1:5706 BENJAMIN CENTER DR
Practice Address - Street 2:SUITE 103
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5262
Practice Address - Country:US
Practice Address - Phone:800-784-0882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS201253336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1014531OtherNCPDP-NABP
BM9458250OtherDEA