Provider Demographics
NPI:1518958081
Name:WILLIAMS, BRENDA R
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 BERKSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5088
Mailing Address - Country:US
Mailing Address - Phone:904-213-9385
Mailing Address - Fax:904-276-1074
Practice Address - Street 1:1833 BOULEVARD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4382
Practice Address - Country:US
Practice Address - Phone:904-232-2751
Practice Address - Fax:904-232-1570
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist