Healthcare Provider Details

I. General information

NPI: 1407972318
Provider Name (Legal Business Name): CASSIE G. ICE R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11406 SAN JOSE BLVD
JACKSONVILLE FL
32223-7963
US

IV. Provider business mailing address

11955 MARBON MEADOWS DR
JACKSONVILLE FL
32223-1900
US

V. Phone/Fax

Practice location:
  • Phone: 904-262-5991
  • Fax: 904-262-7584
Mailing address:
  • Phone: 904-292-1336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS22664
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: