Healthcare Provider Details

I. General information

NPI: 1053554980
Provider Name (Legal Business Name): PSJ PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 N US HIGHWAY 1 STE 1
COCOA FL
32927-5095
US

IV. Provider business mailing address

6801 N US HIGHWAY 1 STE 1
COCOA FL
32927-5095
US

V. Phone/Fax

Practice location:
  • Phone: 321-637-0911
  • Fax: 321-639-0856
Mailing address:
  • Phone: 321-637-0911
  • Fax: 321-639-0856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH23958
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001149900
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
Identifier2119675
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 3
Identifier001149901
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name: RAJESH PATEL
Title or Position: MANAGER
Credential: RPH
Phone: 407-488-6851