Healthcare Provider Details

I. General information

NPI: 1184044810
Provider Name (Legal Business Name): TEJWATIE PREM RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 CYPRESS GARDENS BLVD
WINTER HAVEN FL
33884-4115
US

IV. Provider business mailing address

6015 CYPRESS GARDENS BLVD
WINTER HAVEN FL
33884-4115
US

V. Phone/Fax

Practice location:
  • Phone: 863-326-1612
  • Fax:
Mailing address:
  • Phone: 863-326-1612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS30793
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: