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General NPI Number Information
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NPI Number | 1699465559
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Entity Type | Individual
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Provider Name | BRYAN HENDERSON
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Gender | Male
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Dates
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Enumeration Date | 05/12/2023
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Last Update Date | 05/12/2023
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Provider Practice Location Address
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Address Line | 4854 WOODBINE RD UNIT 5
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City | PACE
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State | FL
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Zip | 32571-8709
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Country | US
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Telephone | 850-463-0022
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Fax | 850-994-7979
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Provider Business Mailing Address
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Address Line | 4854 WOODBINE RD UNIT 5
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City | PACE
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State | FL
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Zip | 32571-8709
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Country | US
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Telephone | 850-463-0022
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Fax | 850-994-7979
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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 | PS29768
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License Number State | FL
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