=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689822348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINN -DIXIE PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2008
-----------------------------------------------------
Last Update Date | 09/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1860 HWY 60 E
-----------------------------------------------------
City | LAKE WALES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33853-4368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-676-2266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1860 HWY 60 E
-----------------------------------------------------
City | LAKE WALES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33853-4368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-676-2266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | MR. STEJO ABRAHAM
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 813-684-9492
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | PS41329
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------