Provider Demographics
NPI:1427230879
Name:BALOTIN, GREGORY H (PHARMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:H
Last Name:BALOTIN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 SAN PABLO RD S STE 17
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2084
Mailing Address - Country:US
Mailing Address - Phone:904-221-8686
Mailing Address - Fax:
Practice Address - Street 1:1650 SAN PABLO RD S STE 17
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2084
Practice Address - Country:US
Practice Address - Phone:904-221-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS33362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS33362OtherSTATE LICENSE NUMBER