Healthcare Provider Details

I. General information

NPI: 1508927237
Provider Name (Legal Business Name): EFRAIN A DELVALLE PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 S PATRICK DRIVE 45TH MEDICAL GROUP
PATRICK AFB FL
32925
US

IV. Provider business mailing address

1381 S PATRICK DRIVE 45TH MEDICAL GROUP
PATRICK AFB FL
32925
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-9313
  • Fax: 321-494-7997
Mailing address:
  • Phone: 321-494-9313
  • Fax: 321-494-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number003803
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: