Healthcare Provider Details

I. General information

NPI: 1902909898
Provider Name (Legal Business Name): IDONGESIT SILAS IDIONG PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 BAY PINES BLVD BAY PINES VA HEALTHCARE SYSTEM
SAINT PETERSBURG FL
33744
US

IV. Provider business mailing address

11850 DR MARTIN LUTHER KING JR ST N APT 6206
SAINT PETERSBURG FL
33716-1626
US

V. Phone/Fax

Practice location:
  • Phone: 727-398-6661
  • Fax:
Mailing address:
  • Phone: 727-374-4515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPS 39314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: