Provider Demographics
NPI:1275879900
Name:MUNDORFF, TERRY D SR (RPH)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:D
Last Name:MUNDORFF
Suffix:SR
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 1:497 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666
Mailing Address - Country:US
Mailing Address - Phone:352-475-1729
Mailing Address - Fax:
Practice Address - Street 1:2720 BLANDING BLVD
Practice Address - Street 2:WINN DIXIE PHARMACY
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-5648
Practice Address - Country:US
Practice Address - Phone:904-282-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS21408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist