Healthcare Provider Details

I. General information

NPI: 1962006759
Provider Name (Legal Business Name): GREG GUDVANGEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 PARKSOUTH CT
ORLANDO FL
32837-6424
US

IV. Provider business mailing address

7120 BRIAR OAK DR
MERRITT ISLAND FL
32953-6701
US

V. Phone/Fax

Practice location:
  • Phone: 407-826-6951
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS40266
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: