| Entity Name: | BURKLOW PHARMACY, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 14 May 1997 (28 years ago) |
| Document Number: | P97000043740 |
| FEI/EIN Number | 593445181 |
| Address: | 2514 Wallace Lake Road, PACE, FL, 32571, US |
| Mail Address: | 2514 Wallace Lake Road, PACE, FL, 32571, US |
| ZIP code: | 32571 |
| County: | Santa Rosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1073558250 | 2006-06-19 | 2016-03-29 | 4880 WOODBINE RD, PACE, FL, 325718762, US | 4880 WOODBINE RD, PACE, FL, 325718762, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 850-995-9999 |
| Fax | 8509950095 |
Authorized person
| Name | STEVE BURKLOW |
| Role | PRESIDENT, PIC |
| Phone | 8502931011 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH15761 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 3336C0004X - Compounding Pharmacy |
| Is Primary | No |
Other Provider Identifiers
| Issuer | PK |
| Number | 2010633 |
| Issuer | MEDICAID |
| Number | 106315400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Sport and Wheat CPA | Agent | 2514 Wallace Lake Rd., Milton, FL, 32571 |
| Name | Role | Address |
|---|---|---|
| BURKLOW STEPHEN A | Vice President | 2514 Wallace Lake Road, PACE, FL, 32571 |
| Name | Role | Address |
|---|---|---|
| BURKLOW MONIQUE H | President | 2514 Wallace Lake Road, PACE, FL, 32571 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G10000093104 | AMERICAN PHARMACY SOLUTIONS | EXPIRED | 2010-10-11 | 2015-12-31 | No data | 5001 COMMERCE PARK CIRCLE, PENSACOLA, FL, 32505 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| AMENDMENT | 2008-05-16 | No data | No data |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
