Provider Demographics
NPI:1376548859
Name:TOLLE, THERESA (RPH)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:TOLLE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5797 TREASURE LN
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:FL
Mailing Address - Zip Code:32949-8203
Mailing Address - Country:US
Mailing Address - Phone:321-733-6508
Mailing Address - Fax:
Practice Address - Street 1:7746 BAY ST
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3427
Practice Address - Country:US
Practice Address - Phone:772-589-2043
Practice Address - Fax:772-388-2628
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL24449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist