MEDICARE: IRAISY PANEQUE PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS37965	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS37965	OTHER	FL	DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE

General Provider Information

NPI Number	:	1225569247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRAISY PANEQUE PHARMD

Provider Business Mailing Address
First Line	:	12620 US HIGHWAY 301
Second Line	:
City	:	DADE CITY
State	:	FL
Zip	:	33525-6058
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12620 US HIGHWAY 301
Second Line	:
City	:	DADE CITY
State	:	FL
Zip	:	33525-6058
Country	:	US
Telephone Number	:	352-521-0155
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	03/22/2017

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Directions to “ IRAISY PANEQUE PHARMD” Practice Location

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