Healthcare Provider Details

I. General information

NPI: 1295072023
Provider Name (Legal Business Name): JIM EAVEY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 STATE ROAD 524
COCOA FL
32926-5819
US

IV. Provider business mailing address

2301 STATE ROAD 524
COCOA FL
32926-5819
US

V. Phone/Fax

Practice location:
  • Phone: 321-636-6784
  • Fax: 321-636-9824
Mailing address:
  • Phone: 321-636-6784
  • Fax: 321-636-9824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS20879
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: