Provider Demographics
NPI:1699227025
Name:ORANGE PARK PHARMACY INC
Entity Type:Organization
Organization Name:ORANGE PARK PHARMACY INC
Other - Org Name:ORANGE PARK PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDALLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:904-579-3027
Mailing Address - Street 1:1992 KINGSLEY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4442
Mailing Address - Country:US
Mailing Address - Phone:904-579-3027
Mailing Address - Fax:904-579-4551
Practice Address - Street 1:1992 KINGSLEY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4442
Practice Address - Country:US
Practice Address - Phone:904-579-3027
Practice Address - Fax:904-579-4551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-02
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH304233336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166209OtherPK
FL023871800Medicaid