MEDICARE: MRS. FANNIE A. INGRAM 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	33406	FL

General Provider Information

NPI Number	:	1356689673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. FANNIE A. INGRAM RPH

Provider Business Mailing Address
First Line	:	5655 RED BUG LAKE RD
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-5013
Country	:	US
Telephone Number	:	407-695-5814
Fax Number	:

Provider Business Practice Location Address
First Line	:	5655 RED BUG LAKE RD
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-5013
Country	:	US
Telephone Number	:	407-695-5814
Fax Number	:

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

Provider Enumeration Date	:	01/21/2013
Last Update Date	:	01/21/2013

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