Provider Demographics
NPI:1457630519
Name:QUALITY SPECIALTY PHARMACY OF JACKSONVILLE INC
Entity Type:Organization
Organization Name:QUALITY SPECIALTY PHARMACY OF JACKSONVILLE INC
Other - Org Name:QUALITY SPECIALTY PHARMACY OF JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AXEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-648-2952
Mailing Address - Street 1:P.O. BOX 16159
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33682
Mailing Address - Country:US
Mailing Address - Phone:904-365-5500
Mailing Address - Fax:904-365-5501
Practice Address - Street 1:6680 POWERS AVE
Practice Address - Street 2:UNIT 110
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2889
Practice Address - Country:US
Practice Address - Phone:904-365-5500
Practice Address - Fax:904-365-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
FLPH254723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004444200Medicaid
2131100OtherPK
FL004444200Medicaid