=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952201584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACOGENOMICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2026
-----------------------------------------------------
Last Update Date | 11/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4531 NW 7TH ST
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33442-9355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-476-4559
-----------------------------------------------------
Fax | 501-476-4559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 390 NE 191ST ST STE 58135
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33179-3899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-476-4559
-----------------------------------------------------
Fax | 501-476-4559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | PAUL JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-476-4559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------