Provider Demographics
NPI:1093886020
Name:WAHLQUIST, LYNNE HOWELL
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:HOWELL
Last Name:WAHLQUIST
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 1:11049 NW STATE RD 20
Mailing Address - Street 2:P.O.BOX 596
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321
Mailing Address - Country:US
Mailing Address - Phone:850-643-5454
Mailing Address - Fax:850-643-5573
Practice Address - Street 1:11049 NW STATE RD 20
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321
Practice Address - Country:US
Practice Address - Phone:850-643-5454
Practice Address - Fax:850-643-5573
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS20151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist