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General NPI Number Information
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NPI Number | 1790407740
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Entity Type | Individual
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Provider Name | ALYSSA BACLIG
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Gender | Female
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Dates
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Enumeration Date | 09/15/2022
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Last Update Date | 09/15/2022
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Provider Practice Location Address
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Address Line | 977 HIGHWAY 98 E
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City | DESTIN
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State | FL
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Zip | 32541-2801
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Country | US
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Telephone | 850-650-4538
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Fax |
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Provider Business Mailing Address
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Address Line | 200 PAGE BACON RD APT 4106
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City | MARY ESTHER
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State | FL
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Zip | 32569-1767
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Country | US
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Telephone | 951-310-8040
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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 | 86147
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 64637
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License Number State | FL
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