| Entity Name: | MOULTRIE PHARMACY, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 04 Feb 2003 (22 years ago) |
| Document Number: | P03000013368 |
| FEI/EIN Number | 542094346 |
| Address: | 3690 US 1 SOUTH, ST AUGUSTINE, FL, 32086 |
| Mail Address: | 3690 US 1 SOUTH, ST AUGUSTINE, FL, 32086 |
| ZIP code: | 32086 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1740270099 | 2005-10-27 | 2017-03-29 | 3690 US HIGHWAY 1 S, ST AUGUSTINE, FL, 320866498, US | 3690 US HIGHWAY 1 S, ST AUGUSTINE, FL, 320866498, US | |||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 904-794-1399 |
| Fax | 9047941193 |
Authorized person
| Name | DELAINE MCCARTY |
| Role | OWNER |
| Phone | 9047941399 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH19146 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 3336C0004X - Compounding Pharmacy |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 025956000 |
| State | FL |
| Issuer | MEDICAID |
| Number | 025956001 |
| State | FL |
| Issuer | PK |
| Number | 2015438 |
| Issuer | MEDICAID |
| Number | 686878996 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MCCARTY ANTHONY O | Agent | 4112 CREEKBLUFF DRIVE, ST AUGUSTINE, FL, 32086 |
| Name | Role | Address |
|---|---|---|
| MCCARTY DELAINE P | President | 4112 CREEKBLUFF DR, ST AUGUSTINE, FL, 32086 |
| Name | Role | Address |
|---|---|---|
| MCCARTY DELAINE P | Director | 4112 CREEKBLUFF DR, ST AUGUSTINE, FL, 32086 |
| MCCARTY ANTHONY O | Director | 4112 CREEKBLUFF DRIVE, ST AUGUSTINE, FL, 32086 |
| Name | Role | Address |
|---|---|---|
| MCCARTY ANTHONY O | Secretary | 4112 CREEKBLUFF DRIVE, ST AUGUSTINE, FL, 32086 |
| Name | Role | Address |
|---|---|---|
| MCCARTY ANTHONY O | Treasurer | 4112 CREEKBLUFF DRIVE, ST AUGUSTINE, FL, 32086 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2009-09-29 | 3690 US 1 SOUTH, ST AUGUSTINE, FL 32086 | No data |
| CHANGE OF MAILING ADDRESS | 2009-09-29 | 3690 US 1 SOUTH, ST AUGUSTINE, FL 32086 | No data |
| REGISTERED AGENT NAME CHANGED | 2004-03-11 | MCCARTY, ANTHONY O | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2004-03-11 | 4112 CREEKBLUFF DRIVE, ST AUGUSTINE, FL 32086 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-02 |
| ANNUAL REPORT | 2023-01-26 |
| ANNUAL REPORT | 2022-01-30 |
| ANNUAL REPORT | 2021-02-04 |
| ANNUAL REPORT | 2020-01-19 |
| ANNUAL REPORT | 2019-01-26 |
| ANNUAL REPORT | 2018-02-06 |
| ANNUAL REPORT | 2017-01-27 |
| ANNUAL REPORT | 2016-03-15 |
| ANNUAL REPORT | 2015-03-31 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
