Provider Demographics
NPI:1629227442
Name:DEPARTMENT OF CHILDREN & FAMILES
Entity Type:Organization
Organization Name:DEPARTMENT OF CHILDREN & FAMILES
Other - Org Name:NORTHEAST FLORIDA STATE HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:904-330-2011
Mailing Address - Street 1:7487 S STATE ROAD 121
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-5451
Mailing Address - Country:US
Mailing Address - Phone:904-259-6211
Mailing Address - Fax:904-259-6709
Practice Address - Street 1:7487 S STATE ROAD 121
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-5451
Practice Address - Country:US
Practice Address - Phone:904-259-6211
Practice Address - Fax:904-259-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026002900Medicaid
FL104007Medicare Oscar/Certification