Provider Demographics
NPI:1952510810
Name:ST OF FL DESOTO JUVENILE CORRECTIONAL FACILITY PHARMACY
Entity Type:Organization
Organization Name:ST OF FL DESOTO JUVENILE CORRECTIONAL FACILITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-491-5367
Mailing Address - Street 1:5871 SE HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-7679
Mailing Address - Country:US
Mailing Address - Phone:863-491-5367
Mailing Address - Fax:863-993-4735
Practice Address - Street 1:5871 SE HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-7679
Practice Address - Country:US
Practice Address - Phone:863-491-5367
Practice Address - Fax:863-993-4735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH184033336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy