Healthcare Provider Details

I. General information

NPI: 1316214810
Provider Name (Legal Business Name): RAELISHA YVETTE HURT RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18310 PINES BLVD
PEMBROKE PINES FL
33029-1412
US

IV. Provider business mailing address

18310 PINES BLVD
PEMBROKE PINES FL
33029-1412
US

V. Phone/Fax

Practice location:
  • Phone: 954-435-8604
  • Fax: 954-441-3176
Mailing address:
  • Phone: 954-435-8604
  • Fax: 954-441-3176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29762
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: