=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811639586
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM STEPHEN BLEDSOE PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2022
-----------------------------------------------------
Last Update Date | 04/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1385 AMELIA PLZ
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-1998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-5306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1440 BUCKNOLL CV
-----------------------------------------------------
City | NEPTUNE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32266-3182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-535-8777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS58975
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------