Provider Demographics
NPI:1992273023
Name:PUBLIC SQUARE PHARMACY LLC
Entity type:Organization
Organization Name:PUBLIC SQUARE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:941-204-1610
Mailing Address - Street 1:2736 UNIVERSITY BLVD W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2179
Mailing Address - Country:US
Mailing Address - Phone:941-204-1610
Mailing Address - Fax:
Practice Address - Street 1:2736 UNIVERSITY BLVD W STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2170
Practice Address - Country:US
Practice Address - Phone:941-204-1610
Practice Address - Fax:904-376-7718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101862900Medicaid