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General NPI Number Information
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NPI Number | 1891193017
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Entity Type | Organization
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Legal Business Name | JEFFERSON PHARMACY LLC
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Dates
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Enumeration Date | 12/22/2014
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Last Update Date | 01/18/2017
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Provider Practice Location Address
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Address Line | 2683 SAINT JOHNS BLUFF RD S STE 127
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City | JACKSONVILLE
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State | FL
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Zip | 32246-3765
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Country | US
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Telephone | 904-516-8278
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Fax | 904-513-9293
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Provider Business Mailing Address
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Address Line | 2683 SAINT JOHNS BLUFF RD S STE 127
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City | JACKSONVILLE
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State | FL
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Zip | 32246-3765
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Country | US
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Telephone | 904-516-8278
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Fax | 904-647-1510
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | CRAIG JOHANSON
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Credential |
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Telephone | 904-638-9515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH28757
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License Number State | FL
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