Healthcare Provider Details

I. General information

NPI: 1134957335
Provider Name (Legal Business Name): MIA KUTANJAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 SAND LAKE RD BLDG 5
ORLANDO FL
32809-7632
US

IV. Provider business mailing address

16632 LAKE TRAIL DR APT 102
CLERMONT FL
34711-1141
US

V. Phone/Fax

Practice location:
  • Phone: 855-797-8254
  • Fax:
Mailing address:
  • Phone: 954-204-2485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS67293
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: