Healthcare Provider Details

I. General information

NPI: 1598696601
Provider Name (Legal Business Name):
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 COMMERCIAL BLVD STE B
LAUDERDALE BY THE SEA FL
33308-4528
US

IV. Provider business mailing address

253 COMMERCIAL BLVD STE B
LAUDERDALE BY THE SEA FL
33308-4528
US

V. Phone/Fax

Practice location:
  • Phone: 954-683-5950
  • Fax:
Mailing address:
  • Phone: 954-331-8536
  • Fax: 954-331-8536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ANDREW JACOBS
Title or Position: MANAGING MEMBER
Credential: PHARMD
Phone: 954-683-5950