Provider Demographics
NPI:1467552604
Name:RAITT, MARC OWEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:OWEN
Last Name:RAITT
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 1:6850 CABALLERO DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2741
Mailing Address - Country:US
Mailing Address - Phone:904-737-6451
Mailing Address - Fax:
Practice Address - Street 1:3627 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4230
Practice Address - Country:US
Practice Address - Phone:904-399-6171
Practice Address - Fax:904-399-6004
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 15502183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist