Provider Demographics
NPI:1558478750
Name:KLEINS OF JACKSONVILLE INC
Entity Type:Organization
Organization Name:KLEINS OF JACKSONVILLE INC
Other - Org Name:KLEIN'S SHOPRITE PHARMACY #563
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:14330 JARRETTSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-1743
Mailing Address - Country:US
Mailing Address - Phone:410-666-1700
Mailing Address - Fax:410-420-8228
Practice Address - Street 1:14330 JARRETTSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-1743
Practice Address - Country:US
Practice Address - Phone:410-666-1700
Practice Address - Fax:410-420-8228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP040813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127581OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MD001843100Medicaid
6522390001Medicare NSC