Provider Demographics
NPI:1124417241
Name:OMJRB LLC
Entity Type:Organization
Organization Name:OMJRB LLC
Other - Org Name:MEDICINE STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VIMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:407-738-0972
Mailing Address - Street 1:2722 W OLD US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-3503
Mailing Address - Country:US
Mailing Address - Phone:407-738-0972
Mailing Address - Fax:877-599-6183
Practice Address - Street 1:2722 W OLD US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-3503
Practice Address - Country:US
Practice Address - Phone:407-738-0972
Practice Address - Fax:877-599-6183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH28791333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH28791OtherPHARMACY LICENSE NUMBER FOR STATE OF FLORIDA