Provider Demographics
NPI:1083809883
Name:NORTH FLORIDA RECEPTION CENTER
Entity Type:Organization
Organization Name:NORTH FLORIDA RECEPTION CENTER
Other - Org Name:NORTH FLORIDA RECEPTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOULDER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:386-496-6534
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-0628
Mailing Address - Country:US
Mailing Address - Phone:386-496-6532
Mailing Address - Fax:386-496-6081
Practice Address - Street 1:7765 S COUNTY ROAD 231
Practice Address - Street 2:DEPT OF CORRECTIONS
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-5721
Practice Address - Country:US
Practice Address - Phone:386-496-6532
Practice Address - Fax:386-496-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
FLPH23873336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005010OtherPK