Healthcare Provider Details

I. General information

NPI: 1952811697
Provider Name (Legal Business Name): ALEASHA X. ICE PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 N YOUNG BLVD
CHIEFLAND FL
32626-1957
US

IV. Provider business mailing address

7472 APACHE TRL
SPRING HILL FL
34606-2507
US

V. Phone/Fax

Practice location:
  • Phone: 352-493-0775
  • Fax:
Mailing address:
  • Phone: 352-610-0327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPSI35947
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS60818
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: