Provider Demographics
NPI:1508870395
Name:FLA A AND M UNIVERSITY STUDENT HLTH PHCY
Entity Type:Organization
Organization Name:FLA A AND M UNIVERSITY STUDENT HLTH PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-412-7881
Mailing Address - Street 1:RM 113 STUDENT HEALTH SERVICES
Mailing Address - Street 2:FOOTE HILVER ADM BUILDING
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RM 113 STUDENT HEALTH SERVICES
Practice Address - Street 2:FOOTE HILVER ADM BUILDING
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32307
Practice Address - Country:US
Practice Address - Phone:850-412-7881
Practice Address - Fax:850-599-3742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH180623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1022209OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1022209OtherOTHER ID NUMBER