Provider Demographics
NPI:1235365495
Name:ST JUDES PHARMACY INC
Entity Type:Organization
Organization Name:ST JUDES PHARMACY INC
Other - Org Name:ST JUDES PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:OTANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-673-7777
Mailing Address - Street 1:1202 NE PINE ISLAND RD
Mailing Address - Street 2:UNIT IV
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2197
Mailing Address - Country:US
Mailing Address - Phone:239-673-7777
Mailing Address - Fax:239-673-7778
Practice Address - Street 1:1202 NE PINE ISLAND RD
Practice Address - Street 2:STE IV
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2197
Practice Address - Country:US
Practice Address - Phone:239-673-7777
Practice Address - Fax:239-673-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH240773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001426500Medicaid
1045841OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1045841OtherNCPDP PROVIDER IDENTIFICATION NUMBER