Provider Demographics
NPI:1144586447
Name:CERAVOLO, JUSTIN RYAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RYAN
Last Name:CERAVOLO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9451 CYPRESS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4909
Mailing Address - Country:US
Mailing Address - Phone:239-481-7322
Mailing Address - Fax:239-481-0151
Practice Address - Street 1:9451 CYPRESS LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4909
Practice Address - Country:US
Practice Address - Phone:239-481-7322
Practice Address - Fax:239-481-0151
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI24223390200000X
FLPS 49258183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program