Provider Demographics
NPI:1518212182
Name:NEPTUNE BEACH PHARMACY LLC
Entity Type:Organization
Organization Name:NEPTUNE BEACH PHARMACY LLC
Other - Org Name:NEPTUNE BEACH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDET
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-619-3450
Mailing Address - Street 1:1529 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-1717
Mailing Address - Country:US
Mailing Address - Phone:904-685-4919
Mailing Address - Fax:904-685-2390
Practice Address - Street 1:1529 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-1717
Practice Address - Country:US
Practice Address - Phone:904-685-4919
Practice Address - Fax:904-685-2390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH262273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5710911OtherNCPDP PROVIDER IDENTIFICATION NUMBER