MEDICARE: VANITA AMANDA HARRIDAN PHARMD

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	PS59962	FL

General Provider Information

NPI Number	:	1477196251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANITA AMANDA HARRIDAN PHARMD

Provider Business Mailing Address
First Line	:	2018 BEARING LN
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34744-5921
Country	:	US
Telephone Number	:	407-271-7544
Fax Number	:

Provider Business Practice Location Address
First Line	:	2750 W NEW HAVEN AVE
Second Line	:
City	:	MELBOURNE VILLAGE
State	:	FL
Zip	:	32904-3706
Country	:	US
Telephone Number	:	321-722-9262
Fax Number	:

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

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	10/23/2019

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