Healthcare Provider Details

I. General information

NPI: 1417148396
Provider Name (Legal Business Name): SERVICE DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5341 BROWN ST.
GRACEVILLE FL
32440
US

IV. Provider business mailing address

P.O. BOX 216
GRACEVILLE FL
32440
US

V. Phone/Fax

Practice location:
  • Phone: 850-263-3257
  • Fax: 850-263-3220
Mailing address:
  • Phone: 850-263-3257
  • Fax: 850-263-3220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH25848
License Number StateFL

VIII. Authorized Official

Name: MRS. STACY M COOK
Title or Position: OWNER/PRESIDENT
Credential: PHARMD
Phone: 850-263-3257