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General NPI Number Information
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NPI Number | 1528399474
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Entity Type | Organization
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Legal Business Name | DJ PHARMACY LLC
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Dates
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Enumeration Date | 01/15/2010
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Last Update Date | 09/19/2011
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Provider Practice Location Address
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Address Line | 5622 MARINE PKWY STE 23
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City | NEW PORT RICHEY
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State | FL
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Zip | 34652-4335
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Country | US
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Telephone | 727-232-0646
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Fax |
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Provider Business Mailing Address
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Address Line | 20122 SHADY HILL LN
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City | TAMPA
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State | FL
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Zip | 33647-3396
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Country | US
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Telephone | 813-495-2234
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | OMOTADE IKUDAYISI
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Credential |
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Telephone | 813-495-2234
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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 | PH24393
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License Number State | FL
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