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General NPI Number Information
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NPI Number | 1427233584
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Entity Type | Organization
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Legal Business Name | LANE AVENUE PHARMACY INC
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Dates
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Enumeration Date | 01/08/2008
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Last Update Date | 06/14/2010
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Provider Practice Location Address
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Address Line | 1233 LANE AVE S STE 9
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City | JACKSONVILLE
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State | FL
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Zip | 32205-6284
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Country | US
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Telephone | 904-693-6633
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Fax | 904-693-6684
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Provider Business Mailing Address
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Address Line | 2595 WATERMILL DR
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City | ORANGE PARK
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State | FL
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Zip | 32073-1621
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Country | US
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Telephone | 904-693-6633
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Fax | 904-693-6684
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Authorized Official
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Title or Position | OWNER / PHARMACIST
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Name | FELIX OBASUYI
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Credential | RPH
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Telephone | 904-693-6633
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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 | PH23097
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License Number State | FL
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