MEDICARE: MRS. CASSIE G. ICE R.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	PS22664	FL

General Provider Information

NPI Number	:	1407972318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CASSIE G. ICE R.PH.

Provider Business Mailing Address
First Line	:	11955 MARBON MEADOWS DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-1900
Country	:	US
Telephone Number	:	904-292-1336
Fax Number	:

Provider Business Practice Location Address
First Line	:	11406 SAN JOSE BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-7963
Country	:	US
Telephone Number	:	904-262-5991
Fax Number	:	904-262-7584

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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