Healthcare Provider Details

I. General information

NPI: 1235733775
Provider Name (Legal Business Name): TIFFANY FRUTH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17450 US HIGHWAY 441
MOUNT DORA FL
32757-6748
US

IV. Provider business mailing address

17450 US HIGHWAY 441
MOUNT DORA FL
32757-6748
US

V. Phone/Fax

Practice location:
  • Phone: 352-385-0747
  • Fax:
Mailing address:
  • Phone: 352-385-0747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS47796
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: