Healthcare Provider Details

I. General information

NPI: 1477666956
Provider Name (Legal Business Name): ISLAND FAMILY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PLANTATION ISLAND DR S, UNIT 3
ST AUGUSTINE FL
32080
US

IV. Provider business mailing address

600 PLANTATION ISLAND DR S, UNIT 3
ST AUGUSTINE FL
32080
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-1081
  • Fax: 904-461-1082
Mailing address:
  • Phone: 904-461-1081
  • Fax: 904-461-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH20073
License Number StateFL

VIII. Authorized Official

Name: RYAN CHRISTOPHER BLANCO
Title or Position: PRESIDENT/ PHARMACY MANAGER
Credential: RPH.
Phone: 904-461-1081