Healthcare Provider Details

I. General information

NPI: 1790975753
Provider Name (Legal Business Name): RUSSELL FREDERICK WIEGAND PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

IV. Provider business mailing address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7406
  • Fax: 904-542-9649
Mailing address:
  • Phone: 904-542-7406
  • Fax: 904-542-9649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS42522
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: