Provider Demographics
NPI:1396184933
Name:PSJ PHARMACY LLC
Entity Type:Organization
Organization Name:PSJ PHARMACY LLC
Other - Org Name:PORT ST. JOHN DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RAJESH
Authorized Official - Middle Name:ARVINDBHAI
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:321-637-0911
Mailing Address - Street 1:6801 N US HIGHWAY 1 STE 1
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-5095
Mailing Address - Country:US
Mailing Address - Phone:321-637-0911
Mailing Address - Fax:321-639-0856
Practice Address - Street 1:6801 N US HIGHWAY 1 STE 1
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-5095
Practice Address - Country:US
Practice Address - Phone:321-637-0911
Practice Address - Fax:321-639-0856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001149901Medicaid