Provider Demographics
NPI:1306291679
Name:FIRST CHOICE PHARMACY LLC
Entity type:Organization
Organization Name:FIRST CHOICE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:BADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:386-219-1988
Mailing Address - Street 1:205 N ARABELLA WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-8022
Mailing Address - Country:US
Mailing Address - Phone:904-708-1661
Mailing Address - Fax:904-800-1388
Practice Address - Street 1:3208 CRILL AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4159
Practice Address - Country:US
Practice Address - Phone:386-219-1988
Practice Address - Fax:386-385-3148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
FLPH293423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017335500Medicaid
2159674OtherPK