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General NPI Number Information
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NPI Number | 1679359293
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Entity Type | Individual
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Provider Name | GRANT DEFALQUE PHARMD
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Gender | Male
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Dates
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Enumeration Date | 09/08/2023
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Last Update Date | 09/08/2023
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Provider Practice Location Address
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Address Line | 5185 US HIGHWAY 98 SOUTH
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City | LAKELAND
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State | FL
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Zip | 33812
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Country | US
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Telephone | 864-644-7969
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Fax |
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Provider Business Mailing Address
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Address Line | 1533 VILLAGE CENTER DR
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City | LAKELAND
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State | FL
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Zip | 33803-2858
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Country | US
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Telephone | 317-847-1368
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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 | PS66309
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License Number State | FL
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