Provider Demographics
NPI:1568525186
Name:NORTH FLORIDA PHARMACY OF KEYSTONE HEIGHTS INC
Entity Type:Organization
Organization Name:NORTH FLORIDA PHARMACY OF KEYSTONE HEIGHTS INC
Other - Org Name:NORTH FLORIDA PHARMACY, MEDICINE SHOPPE 2051
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:AUTRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:352-478-2057
Mailing Address - Street 1:405 S LAWRENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-9222
Mailing Address - Country:US
Mailing Address - Phone:352-478-2057
Mailing Address - Fax:352-478-2059
Practice Address - Street 1:405 S LAWRENCE BLVD
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-9222
Practice Address - Country:US
Practice Address - Phone:352-478-2057
Practice Address - Fax:352-478-2059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH224123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031978300Medicaid
FL031978301Medicaid
2008196OtherPK
2008196OtherPK