MEDICARE: MR. AVON JACKSON PEACOCK RPH

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	PS0016928	FL

General Provider Information

NPI Number	:	1275664807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. AVON JACKSON PEACOCK RPH

Provider Business Mailing Address
First Line	:	2804 CHITTY RD
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33565-5500
Country	:	US
Telephone Number	:	813-754-3053
Fax Number	:	813-719-7902

Provider Business Practice Location Address
First Line	:	205 W ALEXANDER ST
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-7158
Country	:	US
Telephone Number	:	813-754-9449
Fax Number	:	813-719-7902

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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