Provider Demographics
NPI:1013029404
Name:PAN, AI TI (RPH)
Entity Type:Individual
Prefix:MR
First Name:AI TI
Middle Name:
Last Name:PAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:EDDY
Other - Middle Name:
Other - Last Name:PAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4819 FORT LEE CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-7100
Mailing Address - Country:US
Mailing Address - Phone:407-382-5931
Mailing Address - Fax:407-382-5931
Practice Address - Street 1:4686 E MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-5234
Practice Address - Country:US
Practice Address - Phone:407-277-1912
Practice Address - Fax:407-277-2026
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0028034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0556050157Medicare ID - Type Unspecified