Provider Demographics
NPI:1902170889
Name:BAYGREEN PHARMACY CORP
Entity Type:Organization
Organization Name:BAYGREEN PHARMACY CORP
Other - Org Name:BAYGREEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PARUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMTORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-535-7514
Mailing Address - Street 1:PO BOX 600316
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32260-0316
Mailing Address - Country:US
Mailing Address - Phone:904-201-8222
Mailing Address - Fax:904-297-4039
Practice Address - Street 1:9860 BEACH BLVD STE C
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4704
Practice Address - Country:US
Practice Address - Phone:904-201-8222
Practice Address - Fax:904-297-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH259603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005613900Medicaid
2133954OtherPK