Healthcare Provider Details

I. General information

NPI: 1275664807
Provider Name (Legal Business Name): AVON JACKSON PEACOCK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W ALEXANDER ST
PLANT CITY FL
33563-7158
US

IV. Provider business mailing address

2804 CHITTY RD
PLANT CITY FL
33565-5500
US

V. Phone/Fax

Practice location:
  • Phone: 813-754-9449
  • Fax: 813-719-7902
Mailing address:
  • Phone: 813-754-3053
  • Fax: 813-719-7902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS0016928
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: