Provider Demographics
NPI:1497038053
Name:DELISSER, PAUL WILLIAM (RPH)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:WILLIAM
Last Name:DELISSER
Suffix:
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 1:12001 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-4994
Mailing Address - Country:US
Mailing Address - Phone:561-784-7407
Mailing Address - Fax:561-753-0517
Practice Address - Street 1:12001 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-4994
Practice Address - Country:US
Practice Address - Phone:561-784-7407
Practice Address - Fax:561-753-0517
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist