Healthcare Provider Details

I. General information

NPI: 1962728360
Provider Name (Legal Business Name): PRIME PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7685 103RD ST STE 4
JACKSONVILLE FL
32210
US

IV. Provider business mailing address

7685 103RD ST STE 4
JACKSONVILLE FL
32210-9325
US

V. Phone/Fax

Practice location:
  • Phone: 904-813-7634
  • Fax: 904-551-6555
Mailing address:
  • Phone: 904-813-7634
  • Fax: 904-551-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH24868
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SHERAZ MIRZA
Title or Position: COO
Credential:
Phone: 904-551-6555