Healthcare Provider Details

I. General information

NPI: 1891656203
Provider Name (Legal Business Name): MOULTRIE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6498
US

IV. Provider business mailing address

7707 MERRILL RD UNIT 8664
JACKSONVILLE FL
32239-7728
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-1399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KEVIN JOSEPH DUANE
Title or Position: OWNER
Credential:
Phone: 904-765-3531