Provider Demographics
NPI:1477882959
Name:KGJ ENTERPRISES
Entity Type:Organization
Organization Name:KGJ ENTERPRISES
Other - Org Name:SIMFAROSE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-353-1292
Mailing Address - Street 1:6338 LANTANA RD
Mailing Address - Street 2:SUITE 52/53
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467
Mailing Address - Country:US
Mailing Address - Phone:561-353-1292
Mailing Address - Fax:561-353-1293
Practice Address - Street 1:6338 LANTANA RD
Practice Address - Street 2:SUITE 52/53
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467
Practice Address - Country:US
Practice Address - Phone:561-353-1292
Practice Address - Fax:561-353-1293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336S0011X
FLPH243643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5528075Medicaid