MEDICARE: DENTAL RX INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PH21099	FL

General Provider Information

NPI Number	:	1033247986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL RX INC.

Provider Business Mailing Address
First Line	:	1190 EDGEWOOD AVE W
Second Line	:	SUITE B.
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3419
Country	:	US
Telephone Number	:	904-764-8280
Fax Number	:	904-764-6625

Provider Business Practice Location Address
First Line	:	1190 EDGEWOOD AVE W
Second Line	:	SUITE B.
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3419
Country	:	US
Telephone Number	:	904-764-8280
Fax Number	:	904-764-6625

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IRA RILEY JR.
Credential	:	R.P.H.
Telephone Number	:	904-764-8280

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	10/31/2007

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