Provider Demographics
NPI:1578146189
Name:BACON, DAVID JR
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:BACON
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 1:15499 N DALE MABRY HWY APT 209
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1822
Mailing Address - Country:US
Mailing Address - Phone:813-264-6803
Mailing Address - Fax:
Practice Address - Street 1:15499 N DALE MABRY HWY APT 209
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1822
Practice Address - Country:US
Practice Address - Phone:912-223-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist