=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366871774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RX-MART PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2013
-----------------------------------------------------
Last Update Date | 06/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 665 STATE ROAD 207 SUITE 101
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-5938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-342-2162
-----------------------------------------------------
Fax | 904-547-2732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 665 STATE ROAD 207 SUITE 101
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-5938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-342-2162
-----------------------------------------------------
Fax | 904-547-2732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PIC
-----------------------------------------------------
Name | SWAPNA KONDU
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 904-342-2162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH27104
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------