Provider Demographics
NPI:1902295355
Name:JOHN KNOX VILLAGE OF CENTRAL FLORIDA INC
Entity Type:Organization
Organization Name:JOHN KNOX VILLAGE OF CENTRAL FLORIDA INC
Other - Org Name:OAK PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SKELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-456-1500
Mailing Address - Street 1:701 MONASTERY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-6222
Mailing Address - Country:US
Mailing Address - Phone:386-456-1500
Mailing Address - Fax:385-456-1551
Practice Address - Street 1:701 MONASTERY RD STE A
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-6222
Practice Address - Country:US
Practice Address - Phone:386-456-1500
Practice Address - Fax:385-456-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
FLPH288023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014310400Medicaid
2149639OtherPK
2149639OtherPK