Provider Demographics
NPI:1235559469
Name:SETON PHARMACY INC
Entity Type:Organization
Organization Name:SETON PHARMACY INC
Other - Org Name:SETON PHARMACY NORTHSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR,AO
Authorized Official - Prefix:
Authorized Official - First Name:CHARZETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-450-8787
Mailing Address - Street 1:1760 EDGEWOOD AVE W
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-7209
Mailing Address - Country:US
Mailing Address - Phone:904-450-8787
Mailing Address - Fax:904-924-1145
Practice Address - Street 1:1760 EDGEWOOD AVE W STE C
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-7209
Practice Address - Country:US
Practice Address - Phone:904-450-8787
Practice Address - Fax:904-924-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH280433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013794500Medicaid
2148118OtherPK