Provider Demographics
NPI:1265500672
Name:ATKINSON'S MART, INC.
Entity Type:Organization
Organization Name:ATKINSON'S MART, INC.
Other - Org Name:ATKINSON'S HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:WILEY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-298-0873
Mailing Address - Street 1:1994 KINGSLEY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4465
Mailing Address - Country:US
Mailing Address - Phone:904-298-0873
Mailing Address - Fax:
Practice Address - Street 1:1994 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4442
Practice Address - Country:US
Practice Address - Phone:904-298-0873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FLPH171563336C0003X
FLPH284213336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101585100Medicaid
FL0463020002Medicare NSC
FL0922290002Medicare NSC