Provider Demographics
NPI:1427380757
Name:PACK, PHILLIP HOWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:HOWARD
Last Name:PACK
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 1:104 TUSCANY WAY
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2877
Mailing Address - Country:US
Mailing Address - Phone:850-249-7790
Mailing Address - Fax:
Practice Address - Street 1:1329 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2048
Practice Address - Country:US
Practice Address - Phone:850-769-2267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0024637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist