Provider Demographics
NPI:1093597544
Name:PBJ MEDICAL LLC
Entity Type:Organization
Organization Name:PBJ MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:SR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:813-215-9855
Mailing Address - Street 1:13213 SHADY STABLES LANE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527
Mailing Address - Country:US
Mailing Address - Phone:813-215-9855
Mailing Address - Fax:
Practice Address - Street 1:628 MAITLAND AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-6834
Practice Address - Country:US
Practice Address - Phone:800-485-7962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty