Provider Demographics
NPI:1235127804
Name:WORTOCK, MANDY JOHANNES (PHARMD)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:JOHANNES
Last Name:WORTOCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 BAY PINES BLVD
Mailing Address - Street 2:DEPT 119
Mailing Address - City:BAY PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33744
Mailing Address - Country:US
Mailing Address - Phone:727-398-6661
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:DEPT 119
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37609183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist