=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407226392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTERWELL PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2015
-----------------------------------------------------
Last Update Date | 06/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11240 BEACH BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32246-3802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-380-0318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11240 BEACH BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32246-3802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-380-0320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | SEAN LYSINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-580-2376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH29426
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------