=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912501503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESTELLA ARCHIE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2020
-----------------------------------------------------
Last Update Date | 11/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S 6TH AVE
-----------------------------------------------------
City | WAUCHULA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33873-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-767-1195
-----------------------------------------------------
Fax | 863-767-1960
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8955 US HIGHWAY 301 N # 231
-----------------------------------------------------
City | PARRISH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34219-8701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-551-1981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | PS49591
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------