=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841578556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SMART GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2011
-----------------------------------------------------
Last Update Date | 07/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 PARK AVE SUITE 100
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-5571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-541-1511
-----------------------------------------------------
Fax | 904-541-1998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2595 WATERMILL DR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-1621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-505-9720
-----------------------------------------------------
Fax | 904-353-7224
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGRM
-----------------------------------------------------
Name | FELIX OGHOGHO OBASUYI
-----------------------------------------------------
Credential | PHARM.D
-----------------------------------------------------
Telephone | 904-505-9720
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 25599
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------