Healthcare Provider Details

I. General information

NPI: 1902736507
Provider Name (Legal Business Name): EBONY HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2026
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 N PONCE DE LEON BLVD
SAINT AUGUSTINE FL
32084-2603
US

IV. Provider business mailing address

111 WOODCREST DR APT 617
SAINT AUGUSTINE FL
32084-8663
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-2838
  • Fax:
Mailing address:
  • Phone: 904-824-2838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberRPT122891
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: