Provider Demographics
NPI:1912957127
Name:JR PHARMACY PLLC
Entity type:Organization
Organization Name:JR PHARMACY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MBR
Authorized Official - Prefix:
Authorized Official - First Name:ROJER
Authorized Official - Middle Name:
Authorized Official - Last Name:TEWARI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:407-967-8237
Mailing Address - Street 1:2160 WHISPER LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 WHISPER LAKES BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6762
Practice Address - Country:US
Practice Address - Phone:407-447-5612
Practice Address - Fax:407-447-5614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FLPH219943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1018969OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL031430701Medicaid
FL031430700Medicaid
FL031430701Medicaid