Provider Demographics
NPI:1255794350
Name:BLANDING PHARMACY & MEDICAL SUPPLY, LLC
Entity type:Organization
Organization Name:BLANDING PHARMACY & MEDICAL SUPPLY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:904-777-2223
Mailing Address - Street 1:5136 BLANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7894
Mailing Address - Country:US
Mailing Address - Phone:904-777-2223
Mailing Address - Fax:904-777-2787
Practice Address - Street 1:5136 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7894
Practice Address - Country:US
Practice Address - Phone:904-777-2223
Practice Address - Fax:904-777-2787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH25156332B00000X, 3336C0004X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0031111600Medicaid
HU059AMedicare UPIN
FL0031111600Medicaid