Provider Demographics
NPI:1457636367
Name:GERSTLE, MARK (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GERSTLE
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 1:2475 N US 1
Mailing Address - Street 2:
Mailing Address - City:MIMS
Mailing Address - State:FL
Mailing Address - Zip Code:32754-3874
Mailing Address - Country:US
Mailing Address - Phone:321-267-1788
Mailing Address - Fax:321-267-3044
Practice Address - Street 1:2475 N US 1
Practice Address - Street 2:
Practice Address - City:MIMS
Practice Address - State:FL
Practice Address - Zip Code:32754-3874
Practice Address - Country:US
Practice Address - Phone:321-267-1788
Practice Address - Fax:321-267-3044
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0021659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist