MEDICARE: MR. VANCE TAM 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	15796	FL

General Provider Information

NPI Number	:	1407137854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VANCE TAM RPH

Provider Business Mailing Address
First Line	:	8917 SAN JOSE BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-5012
Country	:	US
Telephone Number	:	904-636-8186
Fax Number	:	904-636-8191

Provider Business Practice Location Address
First Line	:	8917 SAN JOSE BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-5012
Country	:	US
Telephone Number	:	904-636-8186
Fax Number	:	904-636-8191

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

Provider Enumeration Date	:	08/30/2011
Last Update Date	:	08/30/2011

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