Provider Demographics
NPI:1477666956
Name:ISLAND FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:ISLAND FAMILY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:904-461-1081
Mailing Address - Street 1:600 PLANTATION ISLAND DR S, UNIT 3
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080
Mailing Address - Country:US
Mailing Address - Phone:904-461-1081
Mailing Address - Fax:904-461-1082
Practice Address - Street 1:600 PLANTATION ISLAND DR S, UNIT 3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080
Practice Address - Country:US
Practice Address - Phone:904-461-1081
Practice Address - Fax:904-461-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH200733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026812700Medicaid
FL026812700Medicaid