NPIMap

Organization Active NPI

St Lukes - St Vincents Healthcare

Doing business as Ascension Rx 1402

  • Community/Retail Pharmacy
  • Jacksonville, FL
National Provider Identifier
1366783441
Registry record updated Jun 3, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
ST LUKES - ST VINCENTS HEALTHCARE
Doing business as
Ascension Rx 1402
Practice address
4205 Belfort Rd Ste 1003
Jacksonville, FL 32216-5876
Phone
(904) 450-6330
Fax
(833) 347-0804
NPI assigned
Mar 14, 2013
Last updated
Jun 3, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 3, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Coba Susan Cornejo
Title
Chief Operating Officer
Phone
(803) 463-5837

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X NU Primary

Addresses

Primary practice location

4205 Belfort Rd Ste 1003
Jacksonville, FL 32216-5876

Mailing address

4201 Belfort Rd Ste G361
Jacksonville, FL 32216-1431
Phone (904) 450-6330

Other names 1

  • Ascension Rx 1402 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20241126001642 FL Part B Supplier - Pharmacy 2668553058 1 other NPI on this enrollment
Practice locations: Jacksonville, FL
O20250428002176 FL DME Supplier - Pharmacy 2668553058 Practice locations: Jacksonville, FL

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
St Lukes-St Vincents Healthcare5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

3 Shircliff Way
Ste 137
Jacksonville, FL 32204
Phone (904) 308-7515

4205 Belfort Rd
Ste 1003
Jacksonville, FL 32216
Phone (904) 296-4299

Ownership & related parties

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Ascension St. Vincent's SouthsideJacksonville, FL, CCN 100307 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 12, 2008
Ascension St. Vincent's SouthsideJacksonville, FL, CCN 10T307 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 12, 2008

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1363219200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1780444800000",
    "number": "1366783441",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4201 BELFORT RD STE G361",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322161431",
            "telephone_number": "904-450-6330",
            "fax_number": "833-347-0804"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4205 BELFORT RD STE 1003",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322165876",
            "telephone_number": "904-450-6330",
            "fax_number": "833-347-0804"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST LUKES - ST VINCENTS HEALTHCARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-03-14",
        "last_updated": "2026-06-03",
        "certification_date": "2026-06-03",
        "status": "A",
        "authorized_official_last_name": "CORNEJO",
        "authorized_official_first_name": "COBA",
        "authorized_official_middle_name": "SUSAN",
        "authorized_official_title_or_position": "CHIEF OPERATING OFFICER",
        "authorized_official_telephone_number": "803-463-5837"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ascension Rx 1402",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksonville, FL

Sources for this page

Verify at the official NPI Registry.