Healthcare Provider Details

I. General information

NPI: 1609908367
Provider Name (Legal Business Name): JSJ OF NORTHWEST FLA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4341 WOODBINE RD SUITE C
PACE FL
32571-8792
US

IV. Provider business mailing address

4341 WOODBINE RD SUITE C
PACE FL
32571-8792
US

V. Phone/Fax

Practice location:
  • Phone: 850-994-9444
  • Fax: 850-995-7772
Mailing address:
  • Phone: 850-994-9444
  • Fax: 850-995-7772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS33955
License Number StateFL

VIII. Authorized Official

Name: DR. WENDA YVONNE SULLIVAN
Title or Position: OWNER, PHARMACIST
Credential: PHARMD, RPH
Phone: 850-994-9444