Provider Demographics
NPI:1639267222
Name:SHANDS JACKSONVILLE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SHANDS JACKSONVILLE MEDICAL CENTER INC
Other - Org Name:SHANDS JACKSONVILLE AMBULATORY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT AND CFO OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COCCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-244-5013
Mailing Address - Street 1:655 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-244-8675
Mailing Address - Fax:904-244-4027
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:1ST FLOOR, ACC BLDG.
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-4542
Practice Address - Fax:904-244-4998
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANDS JACKSONVILLE MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0217042-00Medicaid
1029164OtherNCPDP
FLPH16886OtherPHARMACY LICENSE NUMBER