Provider Demographics
NPI:1275664807
Name:PEACOCK, AVON JACKSON (RPH)
Entity Type:Individual
Prefix:MR
First Name:AVON
Middle Name:JACKSON
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 CHITTY RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33565-5500
Mailing Address - Country:US
Mailing Address - Phone:813-754-3053
Mailing Address - Fax:813-719-7902
Practice Address - Street 1:205 W ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-7158
Practice Address - Country:US
Practice Address - Phone:813-754-9449
Practice Address - Fax:813-719-7902
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0016928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist