Provider Demographics
NPI:1467404806
Name:ACQUAVIVA, CARL D (RPH)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:D
Last Name:ACQUAVIVA
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 1:1260 SARNO RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5204
Mailing Address - Country:US
Mailing Address - Phone:321-242-2440
Mailing Address - Fax:321-242-2125
Practice Address - Street 1:1260 SARNO RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5204
Practice Address - Country:US
Practice Address - Phone:321-242-2440
Practice Address - Fax:321-242-2125
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH 21702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5649100001Medicare ID - Type Unspecified