Provider Demographics
NPI:1083734784
Name:MILLER, MARK A (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:765 HUNT CLUB TRL
Mailing Address - Street 2:PORT ORANGE
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-7796
Mailing Address - Country:US
Mailing Address - Phone:386-238-3239
Mailing Address - Fax:386-238-3263
Practice Address - Street 1:350 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2733
Practice Address - Country:US
Practice Address - Phone:386-248-0832
Practice Address - Fax:386-238-3263
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21022183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist