Healthcare Provider Details

I. General information

NPI: 1457636367
Provider Name (Legal Business Name): MARK GERSTLE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 N US 1
MIMS FL
32754-3874
US

IV. Provider business mailing address

2475 N US 1
MIMS FL
32754-3874
US

V. Phone/Fax

Practice location:
  • Phone: 321-267-1788
  • Fax: 321-267-3044
Mailing address:
  • Phone: 321-267-1788
  • Fax: 321-267-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS0021659
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: