=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306177530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALLAHAN PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2010
-----------------------------------------------------
Last Update Date | 02/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450077 STATE ROAD 200
-----------------------------------------------------
City | CALLAHAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32011-3863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-628-0365
-----------------------------------------------------
Fax | 904-628-0380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2704 SECRET HARBOR DR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065-7675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-651-0055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PHARMACIST IN CHARGE
-----------------------------------------------------
Name | ABDALLA ADAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-651-0055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH24482
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------