MEDICARE: CENTERWELL PHARMACY, 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	3336C0003X	Community/Retail Pharmacy	PH29426	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2154401	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407226392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTERWELL PHARMACY, INC.

Provider Business Mailing Address
First Line	:	11240 BEACH BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-3802
Country	:	US
Telephone Number	:	904-380-0320
Fax Number	:

Provider Business Practice Location Address
First Line	:	11240 BEACH BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-3802
Country	:	US
Telephone Number	:	904-380-0318
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	SEAN LYSINGER
Credential	:
Telephone Number	:	502-580-2376

Provider Enumeration Date	:	10/05/2015
Last Update Date	:	06/12/2025

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