Provider Demographics
NPI:1073512430
Name:ATKINSONS MART INC
Entity Type:Organization
Organization Name:ATKINSONS MART INC
Other - Org Name:ATKINSONS HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-264-7578
Mailing Address - Street 1:100 OLD ORANGE PARK RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3003
Mailing Address - Country:US
Mailing Address - Phone:904-264-7578
Mailing Address - Fax:904-269-8079
Practice Address - Street 1:100 OLD ORANGE PARK RD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-3003
Practice Address - Country:US
Practice Address - Phone:904-264-7578
Practice Address - Fax:904-269-8079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
FLPH24253336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102195800Medicaid
2008643OtherPK
FL102195800Medicaid