Healthcare Provider Details

I. General information

NPI: 1679366652
Provider Name (Legal Business Name): KEVAN KING PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2025
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

124 SAVANNA PRESERVE CT
ST AUGUSTINE FL
32095-8927
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-5155
  • Fax: 904-819-4911
Mailing address:
  • Phone: 321-543-5283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835E0208X
TaxonomyEmergency Medicine Pharmacist
License NumberPS64365
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: