MEDICARE: MR. MARK RONALD HELLER R.PH, C.PH

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	21692	FL

General Provider Information

NPI Number	:	1407857683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK RONALD HELLER R.PH, C.PH

Provider Business Mailing Address
First Line	:	5905 NW 124TH ST
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32653-2639
Country	:	US
Telephone Number	:	352-332-7283
Fax Number	:	352-332-7283

Provider Business Practice Location Address
First Line	:	5905 NW 124TH ST
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32653-2639
Country	:	US
Telephone Number	:	352-332-7283
Fax Number	:	352-332-7283

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/09/2007

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