Provider Demographics
NPI:1427233584
Name:LANE AVENUE PHARMACY INC
Entity Type:Organization
Organization Name:LANE AVENUE PHARMACY INC
Other - Org Name:LANE AVENUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:
Authorized Official - Last Name:OBASUYI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:904-693-6633
Mailing Address - Street 1:2595 WATERMILL DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-1621
Mailing Address - Country:US
Mailing Address - Phone:904-693-6633
Mailing Address - Fax:904-693-6684
Practice Address - Street 1:1233 LANE AVE S
Practice Address - Street 2:STE 9
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-6284
Practice Address - Country:US
Practice Address - Phone:904-693-6633
Practice Address - Fax:904-693-6684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH230973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032420500Medicaid
1031412OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL032420500Medicaid