Healthcare Provider Details

I. General information

NPI: 1720982309
Provider Name (Legal Business Name): CHRISTIAN TYLER LUMBAG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 ATLANTIC BLVD
JACKSONVILLE FL
32266-4000
US

IV. Provider business mailing address

630 ATLANTIC BLVD
JACKSONVILLE FL
32266-4000
US

V. Phone/Fax

Practice location:
  • Phone: 904-249-1725
  • Fax:
Mailing address:
  • Phone: 904-249-1725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS71705
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: