=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992846539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA DEPARTMENT OF HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 11/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 83 PONDELLA RD
-----------------------------------------------------
City | NORTH FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33903-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-461-6148
-----------------------------------------------------
Fax | 239-461-6160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 83 PONDELLA RD
-----------------------------------------------------
City | NORTH FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33903-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-461-6148
-----------------------------------------------------
Fax | 239-461-6160
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT DIRECTOR
-----------------------------------------------------
Name | WILLIAM MALLETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-461-6148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH10694
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------