Provider Demographics
NPI:1093053647
Name:BERISFORD, DONALD EUGENE
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:EUGENE
Last Name:BERISFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 OLD CAMP RD
Mailing Address - Street 2:BUILDING # 170
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5604
Mailing Address - Country:US
Mailing Address - Phone:352-753-1877
Mailing Address - Fax:352-753-3755
Practice Address - Street 1:910 OLD CAMP RD
Practice Address - Street 2:BUILDING # 170
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5604
Practice Address - Country:US
Practice Address - Phone:352-753-1877
Practice Address - Fax:352-753-3755
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 20786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS 20786OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH