Provider Demographics
NPI:1477878379
Name:BASS, WILLARD L JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:L
Last Name:BASS
Suffix:JR
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 1:320 S FERN ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:FL
Mailing Address - Zip Code:32187-2438
Mailing Address - Country:US
Mailing Address - Phone:352-478-5577
Mailing Address - Fax:386-326-0281
Practice Address - Street 1:111 TOWN AND COUNTRY DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3962
Practice Address - Country:US
Practice Address - Phone:386-325-7562
Practice Address - Fax:386-326-0281
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS13424183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist