1891193017 NPI number — JEFFERSON PHARMACY LLC

Table of content: (NPI 1891193017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891193017 NPI number — JEFFERSON PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JEFFERSON PHARMACY, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891193017
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2683 SAINT JOHNS BLUFF RD S STE 127
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32246-3765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-516-8278
Provider Business Mailing Address Fax Number:
904-647-1510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2683 SAINT JOHNS BLUFF RD S STE 127
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32246-3765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-516-8278
Provider Business Practice Location Address Fax Number:
904-513-9293
Provider Enumeration Date:
12/22/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHANSON
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
904-638-9515

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH28757 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2149467 . This is a "PK" identifier . This identifiers is of the category "OTHER".