Provider Demographics
NPI:1366442477
Name:RILEY, IRA JR (PHARMACIST, MBA)
Entity Type:Individual
Prefix:MR
First Name:IRA
Middle Name:
Last Name:RILEY
Suffix:JR
Gender:M
Credentials:PHARMACIST, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 POWERS AVE
Mailing Address - Street 2:APT. 129
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-3858
Mailing Address - Country:US
Mailing Address - Phone:904-636-7770
Mailing Address - Fax:904-764-6625
Practice Address - Street 1:7500 POWERS AVE
Practice Address - Street 2:APT. 129
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-3858
Practice Address - Country:US
Practice Address - Phone:904-636-7770
Practice Address - Fax:904-764-6625
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS32741183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist