Provider Demographics
NPI: | 1477030674 |
---|---|
Name: | MATTHEW 725 INC |
Entity Type: | Organization |
Organization Name: | MATTHEW 725 INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT/OWNER/DIRECTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | STEVEN |
Authorized Official - Middle Name: | THEODORE |
Authorized Official - Last Name: | MOUGEOT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHARMD |
Authorized Official - Phone: | 904-860-4948 |
Mailing Address - Street 1: | 2683 SAINT JOHNS BLUFF RD S STE 135 |
Mailing Address - Street 2: | |
Mailing Address - City: | JACKSONVILLE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32246-3765 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 904-513-4075 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2683 SAINT JOHNS BLUFF RD S STE 135 |
Practice Address - Street 2: | |
Practice Address - City: | JACKSONVILLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32246-3765 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-513-4075 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-07-20 |
Last Update Date: | 2018-07-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PH31462 | 3336C0003X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |