Healthcare Provider Details

I. General information

NPI: 1568128288
Provider Name (Legal Business Name): JOHN CORREA RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10905 N NEBRASKA AVE
TAMPA FL
33612-5724
US

IV. Provider business mailing address

10905 N NEBRASKA AVE
TAMPA FL
33612-5724
US

V. Phone/Fax

Practice location:
  • Phone: 813-971-8401
  • Fax: 813-971-8708
Mailing address:
  • Phone: 813-971-8401
  • Fax: 813-971-8708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberRPT32073
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: