Provider Demographics
NPI:1437750197
Name:JOHN, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 SW SAINT LUCIE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1766
Mailing Address - Country:US
Mailing Address - Phone:772-446-8743
Mailing Address - Fax:772-446-8739
Practice Address - Street 1:902 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1766
Practice Address - Country:US
Practice Address - Phone:772-446-8743
Practice Address - Fax:772-446-8739
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-07
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty