Healthcare Provider Details

I. General information

NPI: 1225582513
Provider Name (Legal Business Name): TIFFANI FAGAN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3914 W COMMERCIAL BLVD
TAMARAC FL
33309-3318
US

IV. Provider business mailing address

3914 W COMMERCIAL BLVD
TAMARAC FL
33309-3318
US

V. Phone/Fax

Practice location:
  • Phone: 954-485-6796
  • Fax:
Mailing address:
  • Phone: 954-485-6796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS55273
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: