Provider Demographics
NPI:1225163397
Name:WARD, MITCHEL (R PH)
Entity Type:Individual
Prefix:
First Name:MITCHEL
Middle Name:
Last Name:WARD
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 CAMELLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-5740
Mailing Address - Country:US
Mailing Address - Phone:850-997-5243
Mailing Address - Fax:
Practice Address - Street 1:1625 W THARPE ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-4664
Practice Address - Country:US
Practice Address - Phone:850-297-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011245183500000X
FLPS0014662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist