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General NPI Number Information
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NPI Number | 1790816072
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Entity Type | Individual
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Provider Name | SIMON B VAN WAGENEN RPH
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Gender | Male
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Dates
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Enumeration Date | 03/08/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 470 W MADISON ST
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City | STARKE
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State | FL
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Zip | 32091-3926
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Country | US
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Telephone | 904-964-6759
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Fax | 904-964-5315
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Provider Business Mailing Address
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Address Line | 15604 SW 161ST ST
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City | BROOKER
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State | FL
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Zip | 32622-2540
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Country | US
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Telephone | 904-449-3937
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Fax | 904-964-5315
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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 | PS16532
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License Number State | FL
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