MEDICARE: BRANDON EMIL PORTER 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	PS5879	FL

General Provider Information

NPI Number	:	1619589686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON EMIL PORTER PHARMD

Provider Business Mailing Address
First Line	:	5340 SOUTEL DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32219-3478
Country	:	US
Telephone Number	:	904-764-1773
Fax Number	:	904-764-3034

Provider Business Practice Location Address
First Line	:	5340 SOUTEL DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32219-3478
Country	:	US
Telephone Number	:	904-764-1773
Fax Number	:	904-764-3034

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

Provider Enumeration Date	:	08/20/2020
Last Update Date	:	08/20/2020

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