MEDICARE: JACQUELYN ROXANNE MUIR

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	RPH030924	GA
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PS53676	FL

General Provider Information

NPI Number	:	1437733680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN ROXANNE MUIR

Provider Business Mailing Address
First Line	:	318 PORT CHARLOTTE DR
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-0526
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	318 PORT CHARLOTTE DR
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-0526
Country	:	US
Telephone Number	:	904-738-4923
Fax Number	:

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

Provider Enumeration Date	:	05/12/2021
Last Update Date	:	05/12/2021

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