Healthcare Provider Details

I. General information

NPI: 1376548859
Provider Name (Legal Business Name): THERESA TOLLE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7746 BAY ST
SEBASTIAN FL
32958-3427
US

IV. Provider business mailing address

5797 TREASURE LN
GRANT FL
32949-8203
US

V. Phone/Fax

Practice location:
  • Phone: 772-589-2043
  • Fax: 772-388-2628
Mailing address:
  • Phone: 321-733-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberFL24449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: