Mycelium Pharmacy LLC

Primary specialty

PharmacyTaxonomy code 333600000X

Legal business name

MYCELIUM PHARMACY LLC

Practice address

141 E Commercial Blvd
Ft Lauderdale, FL 33334-1623

Phone

(954) 616-5675

NPI assigned

Oct 13, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Drew Lauter

Title

Manager/Owner

Phone

(954) 890-1150

Specialties & licenses 1

Addresses

Electronic endpoints 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1602547200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1755302400000",
    "number": "1487252391",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "141 E COMMERCIAL BLVD",
            "city": "FT LAUDERDALE",
            "state": "FL",
            "postal_code": "333341623",
            "telephone_number": "954-890-1150",
            "fax_number": "954-393-0670"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "141 E COMMERCIAL BLVD",
            "city": "FT LAUDERDALE",
            "state": "FL",
            "postal_code": "333341623",
            "telephone_number": "954-616-5675"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MYCELIUM PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-10-13",
        "last_updated": "2025-08-16",
        "certification_date": "2025-08-16",
        "status": "A",
        "authorized_official_last_name": "LAUTER",
        "authorized_official_first_name": "DREW",
        "authorized_official_title_or_position": "MANAGER/OWNER",
        "authorized_official_telephone_number": "954-890-1150",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "myceliumrx@gmail.com",
            "affiliation": "N",
            "endpointDescription": "email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "141 E Commercial Blvd",
            "city": "Ft Lauderdale",
            "state": "FL",
            "country_code": "US",
            "postal_code": "333341623",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 16, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.