Provider Demographics
NPI:1316229057
Name:JOSEPH, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JOSEPH
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 1:4610 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3818
Mailing Address - Country:US
Mailing Address - Phone:954-434-2002
Mailing Address - Fax:
Practice Address - Street 1:5485 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5210
Practice Address - Country:US
Practice Address - Phone:954-977-0494
Practice Address - Fax:954-977-4494
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist