MEDICARE: 45 MDSS PATRICK AFB

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	BW6120656	FL

General Provider Information

NPI Number	:	1467606384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	45 MDSS PATRICK AFB

Provider Business Mailing Address
First Line	:	1381 S. PATRICK DR
Second Line	:
City	:	PATRICK AFB
State	:	FL
Zip	:	32925-4258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1381 S. PATRICK DR.
Second Line	:	45 MDSS
City	:	PATRICK AFB
State	:	FL
Zip	:	32925-3405
Country	:	US
Telephone Number	:	321-494-8991
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST
Name	:	JESSICA S PABON
Credential	:
Telephone Number	:	321-494-8991

Provider Enumeration Date	:	11/05/2008
Last Update Date	:	09/12/2011

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