Provider Demographics
NPI:1477822039
Name:HUMPHREY, JOSEPH D
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:HUMPHREY
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 1:3475 LISMORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5208
Mailing Address - Country:US
Mailing Address - Phone:863-644-3424
Mailing Address - Fax:
Practice Address - Street 1:6710 OLD POLK CITY RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-8300
Practice Address - Country:US
Practice Address - Phone:863-813-3373
Practice Address - Fax:863-815-5303
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34554183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist