=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477878379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLARD L BASS JR. RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2010
-----------------------------------------------------
Last Update Date | 04/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 TOWN AND COUNTRY DR
-----------------------------------------------------
City | PALATKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32177-3962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-325-7562
-----------------------------------------------------
Fax | 386-326-0281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 S FERN ST
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32187-2438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-478-5577
-----------------------------------------------------
Fax | 386-326-0281
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS13424
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------