Healthcare Provider Details

I. General information

NPI: 1558478750
Provider Name (Legal Business Name): KLEINS OF JACKSONVILLE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14330 JARRETTSVILLE PIKE
PHOENIX MD
21131-1743
US

IV. Provider business mailing address

14330 JARRETTSVILLE PIKE
PHOENIX MD
21131-1743
US

V. Phone/Fax

Practice location:
  • Phone: 410-666-1700
  • Fax: 410-420-8228
Mailing address:
  • Phone: 410-666-1700
  • Fax: 410-420-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP04081
License Number StateMD

VIII. Authorized Official

Name: MELISSA FIGUEROA RIVERA
Title or Position: THIRD PARTY ADMINISTRATOR
Credential:
Phone: 732-521-8439