MEDICARE: DOUGLAS WYNN STATEN RPH

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	E-08338	MS
2	183500000X	Pharmacist	PS44814	FL
3	183500000X	Pharmacist	RPH021909	GA

General Provider Information

NPI Number	:	1487721890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS WYNN STATEN RPH

Provider Business Mailing Address
First Line	:	1425 S PENINSULA DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32118-4829
Country	:	US
Telephone Number	:	404-218-9704
Fax Number	:	386-236-9341

Provider Business Practice Location Address
First Line	:	3422 S ATLANTIC AVE
Second Line	:
City	:	DAYTONA BEACH SHORES
State	:	FL
Zip	:	32118-6349
Country	:	US
Telephone Number	:	386-756-0481
Fax Number	:	386-756-0498

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	11/22/2020

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