Provider Demographics
NPI:1376814764
Name:CASTELLOW, MARALICE IDETTE (RPH)
Entity Type:Individual
Prefix:
First Name:MARALICE
Middle Name:IDETTE
Last Name:CASTELLOW
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 1:1650 DUNLAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4754
Mailing Address - Country:US
Mailing Address - Phone:954-303-1664
Mailing Address - Fax:
Practice Address - Street 1:1650 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4754
Practice Address - Country:US
Practice Address - Phone:386-322-3267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30006183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist