Provider Demographics
NPI:1891193017
Name:JEFFERSON PHARMACY LLC
Entity Type:Organization
Organization Name:JEFFERSON PHARMACY LLC
Other - Org Name:JEFFERSON PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-638-9515
Mailing Address - Street 1:2683 SAINT JOHNS BLUFF RD S STE 127
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-3765
Mailing Address - Country:US
Mailing Address - Phone:904-516-8278
Mailing Address - Fax:904-647-1510
Practice Address - Street 1:2683 SAINT JOHNS BLUFF RD S STE 127
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-3765
Practice Address - Country:US
Practice Address - Phone:904-516-8278
Practice Address - Fax:904-513-9293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH287573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149467OtherPK