Provider Demographics
NPI:1467720029
Name:ESTRADA, FABIAN
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:
Last Name:ESTRADA
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 1:10672 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8701
Mailing Address - Country:US
Mailing Address - Phone:239-225-0216
Mailing Address - Fax:239-225-7279
Practice Address - Street 1:10672 COLONIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8701
Practice Address - Country:US
Practice Address - Phone:239-225-0216
Practice Address - Fax:239-225-7279
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist