Provider Demographics
NPI:1073868386
Name:JAG PHARMACY AND HEALTH SERVICES
Entity Type:Organization
Organization Name:JAG PHARMACY AND HEALTH SERVICES
Other - Org Name:45TH STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GANIAT
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUWAMAYOWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-877-9297
Mailing Address - Street 1:5335 N MILITARY TRL STE 44
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3033
Mailing Address - Country:US
Mailing Address - Phone:561-670-2001
Mailing Address - Fax:561-828-8454
Practice Address - Street 1:5335 N MILITARY TRL STE 44
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3033
Practice Address - Country:US
Practice Address - Phone:561-670-2001
Practice Address - Fax:561-828-8454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
FLPH262663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136375OtherPK
FL007284500Medicaid