Provider Demographics
NPI:1689822348
Name:WINN -DIXIE PHARMACY
Entity Type:Organization
Organization Name:WINN -DIXIE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEJO
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:813-684-9492
Mailing Address - Street 1:1860 HWY 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4368
Mailing Address - Country:US
Mailing Address - Phone:863-676-2266
Mailing Address - Fax:
Practice Address - Street 1:1860 HWY 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4368
Practice Address - Country:US
Practice Address - Phone:863-676-2266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41329305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service