Healthcare Provider Details

I. General information

NPI: 1093865693
Provider Name (Legal Business Name): ELISHA YVETTE HANSACK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISHA YVETTE TARVER PHARMD

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD STREET
JACKSONVILLE FL
32214
US

IV. Provider business mailing address

2080 CHILD STREET
JACKSONVILLE FL
32214
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-9412
  • Fax: 904-542-9649
Mailing address:
  • Phone: 904-542-9412
  • Fax: 904-542-9649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS33957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: