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General NPI Number Information
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NPI Number | 1114368644
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Entity Type | Individual
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Provider Name | MARK BERTRAM DODGE BS PHARM
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Gender | Male
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Dates
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Enumeration Date | 07/12/2013
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Last Update Date | 07/12/2013
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Provider Practice Location Address
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Address Line | 975 TAMPA RD
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City | PALM HARBOR
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State | FL
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Zip | 34683-5529
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Country | US
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Telephone | 727-772-8119
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Fax |
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Provider Business Mailing Address
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Address Line | 197 MAYFAIR CIR W
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City | PALM HARBOR
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State | FL
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Zip | 34683-5821
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Country | US
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Telephone | 727-784-1345
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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 | PS19102
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License Number State | FL
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