Provider Demographics
NPI:1881151603
Name:LINCOURT PHARMACY CORP
Entity type:Organization
Organization Name:LINCOURT PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:BANJOKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-341-4000
Mailing Address - Street 1:PO BOX 17175
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-7175
Mailing Address - Country:US
Mailing Address - Phone:727-479-3048
Mailing Address - Fax:727-479-3047
Practice Address - Street 1:501 S LINCOLN AVE STE 10
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5901
Practice Address - Country:US
Practice Address - Phone:727-479-3048
Practice Address - Fax:727-479-3047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LINCOURT PHARMACY CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-28
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108648600Medicaid