MEDICARE: MR. DONALD JOHN DZEJAK 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	PS18294	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS18294	OTHER	FL	PHARMACY LICENSE

General Provider Information

NPI Number	:	1558644542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD JOHN DZEJAK RPH

Provider Business Mailing Address
First Line	:	3340 CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-6536
Country	:	US
Telephone Number	:	407-498-0356
Fax Number	:

Provider Business Practice Location Address
First Line	:	3340 CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-6536
Country	:	US
Telephone Number	:	407-498-0356
Fax Number	:

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

Provider Enumeration Date	:	09/26/2011
Last Update Date	:	09/26/2011

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