Provider Demographics
NPI:1841532108
Name:MAGNOLIA PHARMACY LLC
Entity type:Organization
Organization Name:MAGNOLIA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:CORKREAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-409-1061
Mailing Address - Street 1:12525 CURLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:FL
Mailing Address - Zip Code:33576-7094
Mailing Address - Country:US
Mailing Address - Phone:352-588-3330
Mailing Address - Fax:352-588-3337
Practice Address - Street 1:12525 CURLEY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:FL
Practice Address - Zip Code:33576-7094
Practice Address - Country:US
Practice Address - Phone:352-588-3330
Practice Address - Fax:352-588-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
FLPH267683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139695OtherPK
FL008645900Medicaid