Provider Demographics
NPI:1194078675
Name:MEDIKON LLC
Entity type:Organization
Organization Name:MEDIKON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NISHANT
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-900-7700
Mailing Address - Street 1:7077 NORMANDY BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-6279
Mailing Address - Country:US
Mailing Address - Phone:904-900-7700
Mailing Address - Fax:904-551-0794
Practice Address - Street 1:7077 NORMANDY BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-6279
Practice Address - Country:US
Practice Address - Phone:904-900-7700
Practice Address - Fax:904-551-0794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-20
Last Update Date:2018-04-12
Deactivation Date:2018-03-06
Deactivation Code:
Reactivation Date:2018-04-12
Provider Licenses
StateLicense IDTaxonomies
FLPH264353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008148500Medicaid
FLPH26435OtherFLORIDA BOARD OF PHARMACY
FL008148500Medicaid