=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902385529
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA BLUE O'CONNELL PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2018
-----------------------------------------------------
Last Update Date | 06/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 NW COMMONS LOOP
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32055-7700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-719-5451
-----------------------------------------------------
Fax | 386-719-5456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7839 SW 85TH TER
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32608-5791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-393-9495
-----------------------------------------------------
Fax | 386-719-5456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS58191
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------