Provider Demographics
NPI:1043590581
Name:COLLINS, SIDNEY GRAHAM SR (RPH)
Entity Type:Individual
Prefix:MR
First Name:SIDNEY
Middle Name:GRAHAM
Last Name:COLLINS
Suffix:SR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E INTERNATIONAL SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-2374
Mailing Address - Country:US
Mailing Address - Phone:386-738-4371
Mailing Address - Fax:
Practice Address - Street 1:100 E INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-2374
Practice Address - Country:US
Practice Address - Phone:386-738-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS29300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist