1750460978 NPI number — MR. FRED EARNEST LEE REG PHARMACIST

Table of content: MR. FRED EARNEST LEE REG PHARMACIST (NPI 1750460978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750460978 NPI number — MR. FRED EARNEST LEE REG PHARMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
FRED
Provider Middle Name:
EARNEST
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
REG PHARMACIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750460978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3883 TIMUCUA TRAIL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-743-8942
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1531 MONUMENT ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-998-8999
Provider Business Practice Location Address Fax Number:
904-998-0099
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  FL9914PS009914 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: GA8290RPHO8290 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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