Provider Demographics
NPI:1174509913
Name:HOUSTON, THEODORE ROOSEVELT
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:ROOSEVELT
Last Name:HOUSTON
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 1:2404 MEXIA AVE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32304-1321
Mailing Address - Country:US
Mailing Address - Phone:850-576-4929
Mailing Address - Fax:850-576-4929
Practice Address - Street 1:855 W TENNESSEE ST
Practice Address - Street 2:THAGARD HEALTH CENTER, FLORIDA STATE UNIVERSITY
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32304-7834
Practice Address - Country:US
Practice Address - Phone:850-644-1015
Practice Address - Fax:850-654-5570
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist