Basic Information
Provider Information | |||||||||
NPI: | 1467964494 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA HEALTH CARE PLAN, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FLORIDA HEALTH CARE PLANS PHARMACY-ST. AUGUSTINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1340 RIDGEWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | HOLLY HILL | ||||||||
State: | FL | ||||||||
PostalCode: | 321172320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3866767173 | ||||||||
FaxNumber: | 3866767165 | ||||||||
Practice Location | |||||||||
Address1: | 200 SOUTHPARK BLVD STE 206 | ||||||||
Address2: |   | ||||||||
City: | ST AUGUSTINE | ||||||||
State: | FL | ||||||||
PostalCode: | 320863129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3866767173 | ||||||||
FaxNumber: | 3866767165 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2017 | ||||||||
LastUpdateDate: | 10/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHANDEL | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3866767100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336M0003X | PH31002 | FL | Y |   | Suppliers | Pharmacy | Managed Care Organization Pharmacy |
ID Information
ID | Type | State | Issuer | Description | PH31002 | 01 | FL | STATE LICENSE | OTHER |