Provider Demographics
NPI:1902311046
Name:SPRING PARK PHARMACY LLC
Entity Type:Organization
Organization Name:SPRING PARK PHARMACY LLC
Other - Org Name:SPRING PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-551-5094
Mailing Address - Street 1:4446 HENDRICKS AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6369
Mailing Address - Country:US
Mailing Address - Phone:904-551-5094
Mailing Address - Fax:904-527-1244
Practice Address - Street 1:3851 EMERSON ST STE 13
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-551-5094
Practice Address - Fax:904-527-1244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BN1400X, 3336C0003X
FLPH31080333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175032OtherPK