| Entity Name: | PICH KTM CORP |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 10 Apr 2014 (11 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 28 Oct 2016 (8 years ago) |
| Document Number: | P14000032597 |
| FEI/EIN Number | 46-5374501 |
| Address: | 11643 BEACH BLVD, JACKSONVILLE, FL, 32246, US |
| Mail Address: | 11643 BEACH BLVD, JACKSONVILLE, FL, 32246, US |
| ZIP code: | 32246 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1801354832 | 2019-03-08 | 2023-05-01 | 11643 BEACH BLVD, UNIT A, JACKSONVILLE, FL, 32246, US | 11643 BEACH BLVD, UNIT A, JACKSONVILLE, FL, 32246, US | |||||||||||||||||||||||||
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| Phone | +1 904-551-5870 |
| Fax | 9046196227 |
Authorized person
| Name | MR. CHEN OEUR |
| Role | PHARMACIST/PHARMACY OWNER |
| Phone | 9045515870 |
Taxonomy
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| Is Primary | Yes |
| Taxonomy Code | 3336L0003X - Long Term Care Pharmacy |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 013879700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| OEUR CHEN | Agent | 11643 BEACH BLVD, JACKSONVILLE, FL, 32246 |
| Name | Role | Address |
|---|---|---|
| OEUR CHEN | Director | 11643 BEACH BLVD, JACKSONVILLE, FL, 32246 |
| Name | Role | Address |
|---|---|---|
| Oeur Nakry | Manager | 11643 BEACH BLVD, JACKSONVILLE, FL, 32246 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000043258 | MEDTOWN PHARMACY | ACTIVE | 2020-04-20 | 2025-12-31 | No data | 11643 BEACH BLVD, UNIT A, JACKSONVILLE, FL, 32246 |
| G14000036819 | MEDTOWN PHARMACY | EXPIRED | 2014-04-14 | 2019-12-31 | No data | 13770 BEACH BLVD STE 3, JACKSONVILLE, FL, 32224 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2021-01-28 | 11643 BEACH BLVD, Unit A, JACKSONVILLE, FL 32246 | No data |
| CHANGE OF MAILING ADDRESS | 2021-01-28 | 11643 BEACH BLVD, Unit A, JACKSONVILLE, FL 32246 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-01-28 | 11643 BEACH BLVD, Unit A, JACKSONVILLE, FL 32246 | No data |
| AMENDMENT | 2016-10-28 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-09 |
| ANNUAL REPORT | 2023-04-30 |
| ANNUAL REPORT | 2022-04-26 |
| ANNUAL REPORT | 2021-01-28 |
| ANNUAL REPORT | 2020-06-05 |
| ANNUAL REPORT | 2019-03-08 |
| ANNUAL REPORT | 2018-04-02 |
| ANNUAL REPORT | 2017-03-14 |
| Amendment | 2016-10-28 |
| ANNUAL REPORT | 2016-04-12 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 7162127207 | 2020-04-28 | 0491 | PPP | 13770 Beach Blvd, Suite 3, Jacksonville, FL, 32224 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 02 Feb 2025
Sources: Florida Department of State
