=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770883613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLANDING HEALTH MART PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2010
-----------------------------------------------------
Last Update Date | 05/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5136 BLANDING BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32210-7894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-777-2223
-----------------------------------------------------
Fax | 904-777-2787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5136 BLANDING BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32210-7894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-777-2223
-----------------------------------------------------
Fax | 904-777-2787
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MARCIA R. ATWATER
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 904-777-2223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------