1720051626 NPI number — MS. GLADYS JUNE ALLEN RPH

Table of content: MS. GLADYS JUNE ALLEN RPH (NPI 1720051626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720051626 NPI number — MS. GLADYS JUNE ALLEN RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
GLADYS
Provider Middle Name:
JUNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

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:
1720051626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1164 LINKSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTIC BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32233-4387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-247-3715
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2080 CHILD 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:
32214-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-270-4205
Provider Business Practice Location Address Fax Number:
904-270-4454
Provider Enumeration Date:
02/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  12562 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 942 . This is a "DSN" identifier . This identifiers is of the category "OTHER".
  • Identifier: N00232 . This is a "UIC" identifier . This identifiers is of the category "OTHER".




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