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General NPI Number Information
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NPI Number | 1235365495
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Entity Type | Organization
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Legal Business Name | ST JUDES PHARMACY INC
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Dates
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Enumeration Date | 06/02/2009
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Last Update Date | 08/12/2010
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Provider Practice Location Address
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Address Line | 1202 NE PINE ISLAND RD STE IV
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City | CAPE CORAL
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State | FL
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Zip | 33909-2197
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Country | US
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Telephone | 239-673-7777
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Fax | 239-673-7778
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Provider Business Mailing Address
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Address Line | 1202 NE PINE ISLAND RD UNIT IV
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City | CAPE CORAL
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State | FL
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Zip | 33909-2197
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Country | US
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Telephone | 239-673-7777
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Fax | 239-673-7778
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | JORGE OTANO
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Credential |
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Telephone | 239-673-7777
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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 | PH24077
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License Number State | FL
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