Provider Demographics
NPI:1083261275
Name:ACQUAVIVA, TERYN
Entity Type:Individual
Prefix:
First Name:TERYN
Middle Name:
Last Name:ACQUAVIVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 NE 41ST ST APT A
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064-7398
Mailing Address - Country:US
Mailing Address - Phone:954-980-2691
Mailing Address - Fax:
Practice Address - Street 1:5881 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-4618
Practice Address - Country:US
Practice Address - Phone:954-721-8026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PS59669OtherPHARMACIST LICENSE NUMBER