Provider Demographics
NPI:1336486406
Name:DE LEON, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:DE LEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 HIBERNIA RD STE 200
Mailing Address - Street 2:PUBLIX PHARMACY #1210
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8707
Mailing Address - Country:US
Mailing Address - Phone:904-529-1273
Mailing Address - Fax:904-529-1278
Practice Address - Street 1:865 HIBERNIA RD STE 200
Practice Address - Street 2:PUBLIX PHARMACY #1210
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-8707
Practice Address - Country:US
Practice Address - Phone:904-529-1273
Practice Address - Fax:904-529-1278
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist