1619458981 NPI number — SIMPLYWELL SPECIALTY PHARMACY LP

Table of content: (NPI 1619458981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619458981 NPI number — SIMPLYWELL SPECIALTY PHARMACY LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIMPLYWELL SPECIALTY PHARMACY LP
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:
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:
1619458981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
463128 STATE ROAD 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YULEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32097-5554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-468-3020
Provider Business Mailing Address Fax Number:
904-849-1627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
463128 STATE ROAD 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YULEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32097-5554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-468-8886
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
CLAYTON
Authorized Official First Name:
MADISON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PIC
Authorized Official Telephone Number:
904-468-3020

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  31635 , 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: 101622500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com