Provider Demographics
NPI:1851452676
Name:NORTH BEACHES PHARMACY INC
Entity type:Organization
Organization Name:NORTH BEACHES PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,PRES,AO
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-241-5171
Mailing Address - Street 1:730 BEACH BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5352
Mailing Address - Country:US
Mailing Address - Phone:904-241-5171
Mailing Address - Fax:904-241-0437
Practice Address - Street 1:730 BEACH BLVD STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-241-5171
Practice Address - Fax:904-241-0437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
FLPH79673336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2006425OtherPK
1066790001Medicare NSC