1104839851 NPI number — FLORIDA DEPARTMENT OF HEALTH

Table of content: (NPI 1104839851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104839851 NPI number — FLORIDA DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DEPARTMENT OF HEALTH
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:
Provider Other Organization Name Type Code:
6
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:
1104839851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 NORTH DAVIS STREET
Provider Second Line Business Mailing Address:
BLDG. A, SUITE 251, MC-47
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-253-1530
Provider Business Mailing Address Fax Number:
904-253-1955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 W 6TH ST
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:
32206-4324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-253-1530
Provider Business Practice Location Address Fax Number:
904-253-1955
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LLOYD
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
904-253-1258

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X , with the licence number: PH13640 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 027926914 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2009736 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 027926990 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com