MEDICARE: WENDY ETHRIDGE

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	PS35010	FL
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PU5606	FL

General Provider Information

NPI Number	:	1770904526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY ETHRIDGE

Provider Business Mailing Address
First Line	:	14125 PORTRUSH DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-8241
Country	:	US
Telephone Number	:	407-382-8825
Fax Number	:

Provider Business Practice Location Address
First Line	:	4175 S PIPKIN RD
Second Line	:	SUITE 208
City	:	LAKELAND
State	:	FL
Zip	:	33811-1699
Country	:	US
Telephone Number	:	866-577-1440
Fax Number	:

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

Provider Enumeration Date	:	12/20/2013
Last Update Date	:	12/20/2013

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