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General NPI Number Information
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NPI Number | 1043626153
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Entity Type | Organization
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Legal Business Name | PICH KTM CORP
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Dates
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Enumeration Date | 07/09/2014
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Last Update Date | 05/01/2023
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Provider Practice Location Address
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Address Line | 11643 BEACH BLVD UNIT A
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City | JACKSONVILLE
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State | FL
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Zip | 32246
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Country | US
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Telephone | 904-551-5870
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Fax | 904-619-6227
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Provider Business Mailing Address
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Address Line | 11643 BEACH BLVD UNIT A
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City | JACKSONVILLE
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State | FL
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Zip | 32246
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Country | US
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Telephone | 904-551-5870
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Fax | 904-619-6227
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Authorized Official
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Title or Position | PHARMACIST/PHARMACY OWNER
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Name | MR. CHEN OEUR
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Credential | RPH
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Telephone | 904-551-5870
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH28291
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License Number State | FL
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