Provider Demographics
NPI:1487645305
Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK,LLC
Entity Type:Organization
Organization Name:INTEGRATED COMMUNITY ONCOLOGY NETWORK,LLC
Other - Org Name:ICON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-363-7442
Mailing Address - Street 1:9143 PHILIPS HWY
Mailing Address - Street 2:STE 560
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1348
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:
Practice Address - Street 1:9143 PHILIPS HWY
Practice Address - Street 2:STE 570
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1348
Practice Address - Country:US
Practice Address - Phone:904-519-2720
Practice Address - Fax:904-519-2721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031184700Medicaid
FL5599740001Medicare NSC