MEDICARE: KEILY HERNANDEZ

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	PS55512	FL

General Provider Information

NPI Number	:	1851780258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEILY HERNANDEZ

Provider Business Mailing Address
First Line	:	3304 BONITA BEACH RD
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-4174
Country	:	US
Telephone Number	:	239-495-1700
Fax Number	:

Provider Business Practice Location Address
First Line	:	3304 BONITA BEACH RD
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-4174
Country	:	US
Telephone Number	:	239-495-1700
Fax Number	:

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

Provider Enumeration Date	:	01/22/2015
Last Update Date	:	02/12/2020

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