Healthcare Provider Details

I. General information

NPI: 1689708869
Provider Name (Legal Business Name): CHUKIAT CHAILITILERD RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 S WASHINGTON ST
BEVERLY HILLS FL
34465-4311
US

IV. Provider business mailing address

1577 US HIGHWAY 27 N
AVON PARK FL
33825-2150
US

V. Phone/Fax

Practice location:
  • Phone: 352-270-3243
  • Fax:
Mailing address:
  • Phone: 352-287-4920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS40657
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: