MEDICARE: THALIA MARIA ANDERSON

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	PS34625	FL

General Provider Information

NPI Number	:	1538774054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THALIA MARIA ANDERSON

Provider Business Mailing Address
First Line	:	109 DUMONT PL
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-8014
Country	:	US
Telephone Number	:	904-557-0088
Fax Number	:

Provider Business Practice Location Address
First Line	:	2220 COUNTY ROAD 210 W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-4058
Country	:	US
Telephone Number	:	904-823-2171
Fax Number	:

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

Provider Enumeration Date	:	09/11/2020
Last Update Date	:	09/11/2020

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