Healthcare Provider Details

I. General information

NPI: 1245283423
Provider Name (Legal Business Name): SEASIDE FAMILY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 A1A S STE 102
ST AUGUSTINE FL
32080-6773
US

IV. Provider business mailing address

4075 A1A S STE 102
ST AUGUSTINE FL
32080-6773
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-3299
  • Fax: 904-461-3277
Mailing address:
  • Phone: 904-461-3299
  • Fax: 904-461-3277

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 NumberPH21889
License Number StateFL

VIII. Authorized Official

Name: JAMES PENNINGTON
Title or Position: CO OWNER
Credential: RPH
Phone: 904-461-3299