Provider Demographics
NPI:1003118332
Name:FAHERTY, ADRIENNE B (RPH)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:B
Last Name:FAHERTY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 S PATRICK DR
Mailing Address - Street 2:
Mailing Address - City:PATRICK AIR FORCE BASE
Mailing Address - State:FL
Mailing Address - Zip Code:32925-3606
Mailing Address - Country:US
Mailing Address - Phone:321-494-8991
Mailing Address - Fax:
Practice Address - Street 1:1381 S PATRICK DR
Practice Address - Street 2:
Practice Address - City:PATRICK AIR FORCE BASE
Practice Address - State:FL
Practice Address - Zip Code:32925-3606
Practice Address - Country:US
Practice Address - Phone:321-494-8991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30576183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist