Provider Demographics
NPI:1912292715
Name:TOWN AND COUNTRY PHARMACY, LLC
Entity Type:Organization
Organization Name:TOWN AND COUNTRY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DORBU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-744-0101
Mailing Address - Street 1:939 UNIVERSITY BLVD N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5529
Mailing Address - Country:US
Mailing Address - Phone:904-744-0104
Mailing Address - Fax:
Practice Address - Street 1:939 UNIVERSITY BLVD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5529
Practice Address - Country:US
Practice Address - Phone:904-744-0104
Practice Address - Fax:904-744-0109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003788300Medicaid