Healthcare Provider Details

I. General information

NPI: 1255722443
Provider Name (Legal Business Name): MARY SIEGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 RIVERCHASE DR
TRINITY FL
34655-5721
US

IV. Provider business mailing address

9720 RIVERCHASE DR
TRINITY FL
34655-5721
US

V. Phone/Fax

Practice location:
  • Phone: 813-943-5221
  • Fax:
Mailing address:
  • Phone: 813-943-5221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS52665
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: