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General NPI Number Information
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NPI Number | 1083290761
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Entity Type | Individual
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Provider Name | TARA BOULOS ROECKNER PHARM. D.
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Gender | Female
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Dates
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Enumeration Date | 03/22/2021
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Last Update Date | 03/22/2021
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Provider Practice Location Address
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Address Line | 2109 E STATE ROAD 60
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City | VALRICO
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State | FL
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Zip | 33594-3702
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Country | US
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Telephone | 813-684-0583
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Fax |
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Provider Business Mailing Address
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Address Line | 9210 ESTATE COVE CIR
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City | RIVERVIEW
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State | FL
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Zip | 33578-3103
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Country | US
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Telephone | 561-213-3569
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 60685
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License Number State | FL
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