Healthcare Provider Details

I. General information

NPI: 1265617955
Provider Name (Legal Business Name): AMY BETH FAGAN R.PH., J.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2008
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 PINE RIDGE RD
NAPLES FL
34109-2003
US

IV. Provider business mailing address

2324 PINE RIDGE RD
NAPLES FL
34109-2003
US

V. Phone/Fax

Practice location:
  • Phone: 239-435-0151
  • Fax: 239-330-3472
Mailing address:
  • Phone: 239-435-0151
  • Fax: 239-330-3472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302027330
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10957-40
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS46292
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: