Provider Demographics
NPI:1932244886
Name:STEWARTS PHARMACY AND THE WELLNESS STORE INC
Entity Type:Organization
Organization Name:STEWARTS PHARMACY AND THE WELLNESS STORE INC
Other - Org Name:STEWART'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECT-TREAS
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-216-1021
Mailing Address - Street 1:1350 E MAHAN ST STE B1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-216-1021
Mailing Address - Fax:850-246-1042
Practice Address - Street 1:1350 E MAHAN ST STE B-1
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-216-1021
Practice Address - Fax:850-246-1042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH169833336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136473OtherPK