Provider Demographics
NPI:1376095729
Name:LIQUID LOGIC RX
Entity Type:Organization
Organization Name:LIQUID LOGIC RX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTONIETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-374-0260
Mailing Address - Street 1:5105 BOWDEN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5907
Mailing Address - Country:US
Mailing Address - Phone:904-374-0294
Mailing Address - Fax:
Practice Address - Street 1:5105 BOWDEN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5907
Practice Address - Country:US
Practice Address - Phone:904-374-0294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207L00000X305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258429800Medicaid