| Entity Name: | EBENEZER CLINICAL PHARMACY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 12 Dec 2016 (8 years ago) |
| Last Event: | LC AMENDMENT |
| Event Date Filed: | 22 Dec 2023 (a year ago) |
| Document Number: | L16000224068 |
| FEI/EIN Number | 81-4680818 |
| Address: | 4073 13TH STREET, ST CLOUD, FL, 34769, US |
| Mail Address: | 4073 13TH STREET, ST CLOUD, FL, 34769, US |
| ZIP code: | 34769 |
| County: | Osceola |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1285161083 | 2017-05-11 | 2023-04-10 | 4073 13TH ST, SAINT CLOUD, FL, 34769, US | 4073 13TH ST, SAINT CLOUD, FL, 34769, US | |||||||||||||||||||||||||||||||
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| Phone | +1 407-891-9280 |
| Fax | 4078919200 |
Authorized person
| Name | TINA IHERA |
| Role | PHARMACIST/OWNER |
| Phone | 4079698130 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0002X - Clinic Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH30718 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | PK |
| Number | 2171741 |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| EBENEZER CLINICAL PHARMACY LLC 401K PLAN | 2022 | 814680818 | 2024-03-11 | EBENEZER CLINICAL PHARMACY LLC | 5 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2024-03-11 |
| Name of individual signing | TINA ITTERA |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 446110 |
| Sponsor’s telephone number | 4079794859 |
| Plan sponsor’s address | 4073 13TH ST, SAINT CLOUD, FL, 34769 |
Signature of
| Role | Plan administrator |
| Date | 2022-11-04 |
| Name of individual signing | SAJI THOMAS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 446110 |
| Sponsor’s telephone number | 4079794859 |
| Plan sponsor’s address | 4073 13TH ST, SAINT CLOUD, FL, 34769 |
Signature of
| Role | Plan administrator |
| Date | 2022-11-04 |
| Name of individual signing | SAJI THOMAS |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| Ittera tina | Agent | 4073 13TH STREET, ST CLOUD, FL, 34769 |
| Name | Role | Address |
|---|---|---|
| Ittera Tina | Manager | 4073 13TH STREET, SAINT CLOUD, FL, 34769 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2024-04-19 | Ittera, tina | No data |
| LC AMENDMENT | 2023-12-22 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2019-01-14 | 4073 13TH STREET, ST CLOUD, FL 34769 | No data |
| CHANGE OF MAILING ADDRESS | 2019-01-14 | 4073 13TH STREET, ST CLOUD, FL 34769 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2019-01-14 | 4073 13TH STREET, ST CLOUD, FL 34769 | No data |
| Name | Date |
|---|---|
| AMENDED ANNUAL REPORT | 2024-04-19 |
| AMENDED ANNUAL REPORT | 2024-04-04 |
| ANNUAL REPORT | 2024-03-21 |
| LC Amendment | 2023-12-22 |
| ANNUAL REPORT | 2023-03-30 |
| ANNUAL REPORT | 2022-03-22 |
| ANNUAL REPORT | 2021-04-12 |
| ANNUAL REPORT | 2020-01-29 |
| AMENDED ANNUAL REPORT | 2019-05-29 |
| AMENDED ANNUAL REPORT | 2019-05-17 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
