Provider Demographics
NPI:1972983880
Name:JTJ MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:JTJ MEDICAL SUPPLY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:THEOBALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-939-9226
Mailing Address - Street 1:PO BOX 62134
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-2134
Mailing Address - Country:US
Mailing Address - Phone:800-939-2022
Mailing Address - Fax:855-523-0910
Practice Address - Street 1:1435 DUNN AVE STE 102
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1434
Practice Address - Country:US
Practice Address - Phone:239-939-9226
Practice Address - Fax:855-523-0910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH291363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152348OtherPK
FL101331800Medicaid