Healthcare Provider Details

I. General information

NPI: 1457945487
Provider Name (Legal Business Name): HEATHER TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2021
Last Update Date: 02/20/2021
Certification Date: 02/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 MOODY BLVD
FLAGLER BEACH FL
32136-4427
US

IV. Provider business mailing address

348 CRESCENT KEY DR
SAINT AUGUSTINE FL
32086-2928
US

V. Phone/Fax

Practice location:
  • Phone: 386-439-6271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS50505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: