Provider Demographics
NPI:1225100621
Name:BLOUNTSTOWN DRUG INC.
Entity Type:Organization
Organization Name:BLOUNTSTOWN DRUG INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:PLUMMER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:850-674-2222
Mailing Address - Street 1:20370 CENTRAL AVE W
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1945
Mailing Address - Country:US
Mailing Address - Phone:850-674-2222
Mailing Address - Fax:
Practice Address - Street 1:20370 CENTRAL AVE W
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1945
Practice Address - Country:US
Practice Address - Phone:850-674-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH21495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5519620001Medicare NSC