Provider Demographics
NPI:1477195824
Name:ELISME, THEODORE
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:ELISME
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 1:12130 NE MIAMI PL
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5359
Mailing Address - Country:US
Mailing Address - Phone:954-296-4399
Mailing Address - Fax:
Practice Address - Street 1:12130 NE MIAMI PL
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5359
Practice Address - Country:US
Practice Address - Phone:954-296-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL59957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59957OtherPHARMACY
FL59957Medicaid