Healthcare Provider Details

I. General information

NPI: 1861720559
Provider Name (Legal Business Name): MARK CASEY PHILLIPS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MAIN ST
HASTINGS FL
32145
US

IV. Provider business mailing address

PO BOX 640
HASTINGS FL
32145-0640
US

V. Phone/Fax

Practice location:
  • Phone: 904-692-4748
  • Fax: 904-692-1085
Mailing address:
  • Phone: 904-692-4748
  • Fax: 904-692-1085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH24460
License Number StateFL

VIII. Authorized Official

Name: MARK PHILLIPS
Title or Position: PRESIDENT/PHCY OWNER
Credential:
Phone: 904-692-4748