=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629495536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUARDIAN PHARMACY OF JACKSONVILLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2014
-----------------------------------------------------
Last Update Date | 03/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8000 BELFORT PKWY SUITE 200
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-6934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-345-4301
-----------------------------------------------------
Fax | 904-296-0604
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8000 BELFORT PKWY SUITE 200
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-6934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KHRISTY MCCLELLAND
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 904-345-4301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | PS31724
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------