Provider Demographics
NPI:1467954438
Name:DE2 LLC
Entity Type:Organization
Organization Name:DE2 LLC
Other - Org Name:PANAMA PHARMACY #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-990-1054
Mailing Address - Street 1:7707 MERRILL RD UNIT 8664
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32239-7728
Mailing Address - Country:US
Mailing Address - Phone:904-351-6434
Mailing Address - Fax:
Practice Address - Street 1:6022 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-7503
Practice Address - Country:US
Practice Address - Phone:904-990-1054
Practice Address - Fax:904-990-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-06
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
FLPH312273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025153200Medicaid
2176263OtherPK