=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235589888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERON DOUGLAS PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2016
-----------------------------------------------------
Last Update Date | 07/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4459 WHISPERING INLET DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32277-1136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-368-1886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2010 SW COLLEGE RD
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-1620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-368-1886
-----------------------------------------------------
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 | PS53880
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------