Provider Demographics
NPI:1467606384
Name:45 MDSS PATRICK AFB
Entity Type:Organization
Organization Name:45 MDSS PATRICK AFB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PABON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-494-8991
Mailing Address - Street 1:1381 S. PATRICK DR
Mailing Address - Street 2:
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1381 S. PATRICK DR.
Practice Address - Street 2:45 MDSS
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3405
Practice Address - Country:US
Practice Address - Phone:321-494-8991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBW6120656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty