Provider Demographics
NPI:1043626153
Name:PICH KTM CORP
Entity type:Organization
Organization Name:PICH KTM CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PHARMACY OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OEUR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:904-551-5870
Mailing Address - Street 1:11643 BEACH BLVD
Mailing Address - Street 2:UNIT A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246
Mailing Address - Country:US
Mailing Address - Phone:904-551-5870
Mailing Address - Fax:904-619-6227
Practice Address - Street 1:11643 BEACH BLVD
Practice Address - Street 2:UNIT A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246
Practice Address - Country:US
Practice Address - Phone:904-551-5870
Practice Address - Fax:904-619-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH282913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013879700Medicaid
2147617OtherPK