Provider Demographics
NPI:1043776057
Name:OUTREACH COMMUNITY CARE NETWORK INC
Entity Type:Organization
Organization Name:OUTREACH COMMUNITY CARE NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:386-675-0098
Mailing Address - Street 1:240 N. FREDERICK AVENUE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114
Mailing Address - Country:US
Mailing Address - Phone:386-675-0118
Mailing Address - Fax:386-257-1245
Practice Address - Street 1:240 N. FREDERICK AVENUE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-675-0118
Practice Address - Fax:386-257-1245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUTREACH COMMUNITY CARE NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy