Provider Demographics
NPI:1073124863
Name:FRASER, TIFFANY JADE HARRIS (PHARMD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JADE HARRIS
Last Name:FRASER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 S SR 19
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177
Mailing Address - Country:US
Mailing Address - Phone:386-328-6787
Mailing Address - Fax:
Practice Address - Street 1:14500 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-7858
Practice Address - Country:US
Practice Address - Phone:904-964-3290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist