Provider Demographics
NPI:1033467097
Name:PEREZ, RONALD ANTHONY
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:ANTHONY
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16400 STATE ROAD 54
Mailing Address - Street 2:T-2209
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-3720
Mailing Address - Country:US
Mailing Address - Phone:813-383-0011
Mailing Address - Fax:813-448-2810
Practice Address - Street 1:16400 STATE ROAD 54
Practice Address - Street 2:T-2209
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-3720
Practice Address - Country:US
Practice Address - Phone:813-383-0011
Practice Address - Fax:813-448-2810
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-24
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12312183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist