Healthcare Provider Details

I. General information

NPI: 1902191612
Provider Name (Legal Business Name): LEE PAUL TIBBITTS JR. RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CROCKETT BLVD
MERRITT ISLAND FL
32953-4395
US

IV. Provider business mailing address

250 CROCKETT BLVD
MERRITT ISLAND FL
32953-4395
US

V. Phone/Fax

Practice location:
  • Phone: 321-452-1691
  • Fax: 321-452-1691
Mailing address:
  • Phone: 321-452-1691
  • Fax: 321-452-1691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS0028651
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18651
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: