Provider Demographics
NPI:1558073114
Name:DELOACH, WILLIAM EDWARD JR
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDWARD
Last Name:DELOACH
Suffix:JR
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 1:929 WALNUT ST APT A
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-6317
Mailing Address - Country:US
Mailing Address - Phone:321-634-2044
Mailing Address - Fax:
Practice Address - Street 1:1185 FAY BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-8742
Practice Address - Country:US
Practice Address - Phone:321-639-4650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103205183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician