=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477030674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATTHEW 725 INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2018
-----------------------------------------------------
Last Update Date | 07/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2683 SAINT JOHNS BLUFF RD S STE 135
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32246-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-513-4075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2683 SAINT JOHNS BLUFF RD S STE 135
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32246-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-513-4075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER/DIRECTOR
-----------------------------------------------------
Name | DR. STEVEN THEODORE MOUGEOT
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 904-860-4948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH31462
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------