Healthcare Provider Details

I. General information

NPI: 1366871774
Provider Name (Legal Business Name): RX-MART PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 STATE ROAD 207 SUITE 101
ST AUGUSTINE FL
32084-5938
US

IV. Provider business mailing address

665 STATE ROAD 207 SUITE 101
ST AUGUSTINE FL
32084-5938
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-2162
  • Fax: 904-547-2732
Mailing address:
  • Phone: 904-342-2162
  • Fax: 904-547-2732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH27104
License Number StateFL

VIII. Authorized Official

Name: SWAPNA KONDU
Title or Position: PIC
Credential: RPH
Phone: 904-342-2162