Healthcare Provider Details

I. General information

NPI: 1295042133
Provider Name (Legal Business Name): JYA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 SOUTH BLVD W
DAVENPORT FL
33837-7002
US

IV. Provider business mailing address

2200 SOUTH BLVD W
DAVENPORT FL
33837-7002
US

V. Phone/Fax

Practice location:
  • Phone: 863-421-9200
  • Fax: 863-421-9220
Mailing address:
  • Phone: 863-421-9200
  • Fax: 863-421-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH24823
License Number StateFL

VIII. Authorized Official

Name: DR. YAHAYA FIDELIS ABUH
Title or Position: PHARMACY MANAGER/OWNER
Credential: PHD, RPH
Phone: 863-330-0681