Provider Demographics
NPI:1043414782
Name:NORTH FLORIDA PHARMACY OF FORT WHITE INC
Entity Type:Organization
Organization Name:NORTH FLORIDA PHARMACY OF FORT WHITE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:352-871-0819
Mailing Address - Street 1:7729 SOUTHWEST US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038
Mailing Address - Country:US
Mailing Address - Phone:386-497-2580
Mailing Address - Fax:386-497-4227
Practice Address - Street 1:7729 SW US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038-3508
Practice Address - Country:US
Practice Address - Phone:386-497-2580
Practice Address - Fax:386-497-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH22706332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032073101Medicaid
FL032073100Medicaid
FL032073100Medicaid