EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, PA
Pharmacy at Mar Walt Dr, Fort Walton Beach, FL

License number
Florida PH30219
Category
Suppliers
Type
Pharmacy
Owner
Name: TAMMIE MISKIMINS
Title: MANAGER, PHARMACY LICENSING/CONTRAC
Phone: (817) 572-0009
Address
Address 2
917 Mar Walt Dr STE C, Fort Walton Beach, FL 32547
1620 W. Hwy NORTHWEST SUITE 100, Grapevine, TX 76051
National Provider ID: 1154773950
LicenseFiles verified this license of Nov 7, 2017 at the National Plan and Provider Enumeration System.

Organization information

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EMERALD COAST INFECTIOUS DISEASES MEDICAL GROUP, PA

917 Mar Walt Dr, Fort Walton Beach, FL 32547

Status:
Inactive
Inactive reason:
CANCEL ADM DISS/REV
Registration:
Oct 4, 2004
Inactive since:
Jan 9, 2006
State ID:
P04000137184
Business type:
Florida Profit Corporation
Chairman, Secretarys:
Patrick Dr Anastasio (President, Treasurer, Director, Secretary), 917 Mar Walt Dr Sute, Fort Walton Beach, FL 32547 (Physical),Sandra Anastasio (Treasurer, Secretary, Vice President), 917 Mar Walt Dr, Fort Walton Beach, FL 32547 (Physical),Robin Asec Snyder (Chairman, Secretary), 917 Mar Walt, Fort Walton Beach, FL 32547 (Physical)
Agent:
Anastasio, Sandra,917 Mar Walt Dr, Fort Walton Beach, FL 32547 (Physical)
EIN:
562483799

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