Healthcare Provider Details

I. General information

NPI: 1194055244
Provider Name (Legal Business Name): ROCK 3
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 US HIGHWAY 1
MIMS FL
32754-3854
US

IV. Provider business mailing address

PO BOX 410917
MELBOURNE FL
32941-0917
US

V. Phone/Fax

Practice location:
  • Phone: 321-567-4919
  • Fax:
Mailing address:
  • Phone: 850-292-1917
  • Fax: 321-259-3330

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 NumberPH24391
License Number StateFL

VIII. Authorized Official

Name: JOHN ONI
Title or Position: PHARMACY MANAGER
Credential:
Phone: 850-292-1917