Healthcare Provider Details

I. General information

NPI: 1902295355
Provider Name (Legal Business Name): JOHN KNOX VILLAGE OF CENTRAL FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MONASTERY RD STE A
ORANGE CITY FL
32763-6222
US

IV. Provider business mailing address

701 MONASTERY RD SUITE A
ORANGE CITY FL
32763-6222
US

V. Phone/Fax

Practice location:
  • Phone: 386-456-1500
  • Fax: 385-456-1551
Mailing address:
  • Phone: 386-456-1500
  • Fax: 385-456-1551

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 NumberPH28802
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PAUL SKELTON
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 386-456-1500