| Entity Name: | MULBERRY LTC PHARMACY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Co. |
| Status: | Active |
| Date Filed: | 12 Dec 2019 (5 years ago) |
| Branch of: | MULBERRY LTC PHARMACY, LLC, MISSISSIPPI (Company Number 1180128) |
| Document Number: | M20000000026 |
| FEI/EIN Number | 842732600 |
| Address: | 1011 N CHURCH AVE, MULBERRY, FL, 33860, US |
| Mail Address: | 3260 Shady Oaks Drive, Olive Branch, MS, 38654, US |
| ZIP code: | 33860 |
| County: | Polk |
| Place of Formation: | MISSISSIPPI |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1750561619 | 2007-11-08 | 2022-07-21 | PO BOX 797, MULBERRY, FL, 338600797, US | 1011 N CHURCH AVE, MULBERRY, FL, 338602039, US | |||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||
| Phone | +1 863-425-1101 |
| Fax | 8634252802 |
Authorized person
| Name | BECKY LYNN PRESTON |
| Role | VICE PRESIDENT |
| Phone | 8634251101 |
Taxonomy
| Taxonomy Code | 3336L0003X - Long Term Care Pharmacy |
| License Number | PH22964 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 3336L0003X - Long Term Care Pharmacy |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 032380200 |
| State | FL |
| Issuer | PK |
| Number | 2010229 |
| Name | Role | Address |
|---|---|---|
| PRESTON BECKY | Agent | 1011 N CHURCH AVE, MULBERRY, FL, 33860 |
| Name | Role | Address |
|---|---|---|
| PRESTON BECKY | Vice President | 1011 N CHURCH AVE, MULBERRY, FL, 33860 |
| Name | Role | Address |
|---|---|---|
| PRESTON BECKY | Officer | 1011 N CHURCH AVE, MULBERRY, FL, 33860 |
| Name | Role | Address |
|---|---|---|
| MUELLER ELAINE | Chief Executive Officer | 3260 Shady Oaks Drive, Olive Branch, MS, 38654 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2021-04-15 | 1011 N CHURCH AVE, MULBERRY, FL 33860 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-09 |
| ANNUAL REPORT | 2023-03-09 |
| ANNUAL REPORT | 2022-02-16 |
| ANNUAL REPORT | 2021-04-15 |
| ANNUAL REPORT | 2020-06-09 |
| Foreign Limited | 2019-12-12 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
