=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720352776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OM SHRI GANESH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2012
-----------------------------------------------------
Last Update Date | 03/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7628 103RD ST STE 5
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32210-8719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-900-3500
-----------------------------------------------------
Fax | 904-900-3505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7628 103RD ST STE 5
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32210-8719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-900-3500
-----------------------------------------------------
Fax | 904-900-3505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | TEJAS PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-208-8137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH25990
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------