=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104792688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN JOSEPH MAGSINO ILAO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2025
-----------------------------------------------------
Last Update Date | 10/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 NE PINE ISLAND RD
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33909-1797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-242-1050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8332 FREE AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32211-9631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-471-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS69428
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------