MEDICARE: MR. THEODORE ROOSEVELT HOUSTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	12648	FL

General Provider Information

NPI Number	:	1174509913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THEODORE ROOSEVELT HOUSTON

Provider Business Mailing Address
First Line	:	2404 MEXIA AVE
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32304-1321
Country	:	US
Telephone Number	:	850-576-4929
Fax Number	:	850-576-4929

Provider Business Practice Location Address
First Line	:	855 W TENNESSEE ST
Second Line	:	THAGARD HEALTH CENTER, FLORIDA STATE UNIVERSITY
City	:	TALLAHASSEE
State	:	FL
Zip	:	32304-7834
Country	:	US
Telephone Number	:	850-644-1015
Fax Number	:	850-654-5570

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	07/08/2007

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