MEDICARE: CODY BALLANCE

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	PS 46832	FL

General Provider Information

NPI Number	:	1528330628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY BALLANCE

Provider Business Mailing Address
First Line	:	100 4TH AVE S APT 228
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33701-4370
Country	:	US
Telephone Number	:	727-465-6699
Fax Number	:

Provider Business Practice Location Address
First Line	:	337 75TH AVE
Second Line	:
City	:	ST PETE BEACH
State	:	FL
Zip	:	33706-1829
Country	:	US
Telephone Number	:	727-367-7657
Fax Number	:

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

Provider Enumeration Date	:	02/04/2012
Last Update Date	:	02/04/2012

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Directions to “ CODY BALLANCE ” Practice Location

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