Provider Demographics
NPI:1003211947
Name:ACQUAVIVA, CARLY (PHARM D)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ACQUAVIVA
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 PORT MALABAR BLVD NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5407
Mailing Address - Country:US
Mailing Address - Phone:321-725-7188
Mailing Address - Fax:
Practice Address - Street 1:1555 PORT MALABAR BLVD NE
Practice Address - Street 2:SUITE 101
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5407
Practice Address - Country:US
Practice Address - Phone:321-725-7188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist