Provider Demographics
NPI:1609908367
Name:JSJ OF NORTHWEST FLA, INC
Entity type:Organization
Organization Name:JSJ OF NORTHWEST FLA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDA
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:850-994-9444
Mailing Address - Street 1:4341 WOODBINE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8792
Mailing Address - Country:US
Mailing Address - Phone:850-994-9444
Mailing Address - Fax:850-995-7772
Practice Address - Street 1:4341 WOODBINE RD
Practice Address - Street 2:SUITE C
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8792
Practice Address - Country:US
Practice Address - Phone:850-994-9444
Practice Address - Fax:850-995-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS33955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4501270001Medicare ID - Type Unspecified