MEDICARE: FOSUYI ENTERPRISE

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	PH25006	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5702382	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1538469028
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOSUYI ENTERPRISE

Provider Business Mailing Address
First Line	:	2595 WATERMILL DR
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-1621
Country	:	US
Telephone Number	:	904-505-9720
Fax Number	:	904-693-6684

Provider Business Practice Location Address
First Line	:	5312 N PEARL ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-5119
Country	:	US
Telephone Number	:	904-353-7223
Fax Number	:	904-353-7224

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	FELIX OBASUYI
Credential	:
Telephone Number	:	904-353-7223

Provider Enumeration Date	:	10/30/2010
Last Update Date	:	02/01/2011

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Directions to “FOSUYI ENTERPRISE ” Practice Location

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