Healthcare Provider Details

I. General information

NPI: 1912899584
Provider Name (Legal Business Name): EMILY PEABODY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

2808 NW 109TH AVE
SUNRISE FL
33322-1841
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS62744
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: