Healthcare Provider Details

I. General information

NPI: 1801354832
Provider Name (Legal Business Name): PICH KTM CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11643 BEACH BLVD UNIT A
JACKSONVILLE FL
32246
US

IV. Provider business mailing address

11643 BEACH BLVD UNIT A
JACKSONVILLE FL
32246
US

V. Phone/Fax

Practice location:
  • Phone: 904-551-5870
  • Fax: 904-619-6227
Mailing address:
  • Phone: 904-551-5870
  • Fax: 904-619-6227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. CHEN OEUR
Title or Position: PHARMACIST/PHARMACY OWNER
Credential: RPH
Phone: 904-551-5870