Provider Demographics
NPI:1396413621
Name:CACERES, RAFAEL R JR (CEO BBA, RPT)
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:R
Last Name:CACERES
Suffix:JR
Gender:M
Credentials:CEO BBA, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E ROBERTSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5254
Mailing Address - Country:US
Mailing Address - Phone:813-781-0250
Mailing Address - Fax:813-681-6570
Practice Address - Street 1:207 E ROBERTSON ST STE B
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5254
Practice Address - Country:US
Practice Address - Phone:813-781-0250
Practice Address - Fax:813-681-6570
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT18988183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003977800Medicaid