1992047260 NPI number — MEDCITY PHARMACY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992047260 NPI number — MEDCITY PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDCITY PHARMACY
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:
1992047260
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11988 MARLDON LN
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:
32258-9459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-252-1568
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
463688 SR 200
Provider Second Line Business Practice Location Address:
SUITE #6
Provider Business Practice Location Address City Name:
YULEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-432-3810
Provider Business Practice Location Address Fax Number:
904-432-3811
Provider Enumeration Date:
03/25/2013

Additional Information

Authorized Official

Authorized Official Last Name:
EDARA
Authorized Official First Name:
SUMANTH
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
904-252-1568

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PH26731 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5713816 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008883200 . 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