Provider Demographics
NPI:1306183181
Name:ISENBERG, JIM (RPH)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:ISENBERG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 COUNTY ROAD 210 W
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-2016
Mailing Address - Country:US
Mailing Address - Phone:904-230-3933
Mailing Address - Fax:
Practice Address - Street 1:2845 COUNTY ROAD 210 W
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-2016
Practice Address - Country:US
Practice Address - Phone:904-230-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-13
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19160183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist