Provider Demographics
NPI:1174267959
Name:ICABALZETA, ERIKA MASSIEL
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:MASSIEL
Last Name:ICABALZETA
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 1:2424 SAND MINE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-3400
Mailing Address - Country:US
Mailing Address - Phone:863-424-9973
Mailing Address - Fax:863-424-9980
Practice Address - Street 1:2424 SAND MINE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-3400
Practice Address - Country:US
Practice Address - Phone:863-424-9973
Practice Address - Fax:863-424-9980
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT104486183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician