1194078675 NPI number — MEDIKON LLC

Table of content: (NPI 1194078675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194078675 NPI number — MEDIKON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDIKON 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:
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:
1194078675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/06/2018
NPI Reactivation Date:
04/12/2018

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7077 NORMANDY BLVD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32205-6279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-900-7700
Provider Business Mailing Address Fax Number:
904-551-0794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7077 NORMANDY BLVD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32205-6279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-900-7700
Provider Business Practice Location Address Fax Number:
904-551-0794
Provider Enumeration Date:
10/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
NISHANT
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
904-900-7700

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH26435 , 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: 008148500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH26435 . This is a "FLORIDA BOARD OF PHARMACY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 018566900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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