Provider Demographics
NPI:1417624222
Name:WILLIAMS, CORBETT ROSS (RPH)
Entity Type:Individual
Prefix:
First Name:CORBETT
Middle Name:ROSS
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 KINGS COURT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:904-463-6354
Mailing Address - Fax:
Practice Address - Street 1:4901 GATE PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4405
Practice Address - Country:US
Practice Address - Phone:904-790-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-28
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist