Provider Demographics
NPI:1619421179
Name:HARPER, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:HARPER
Suffix:
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 1:1830 N ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3287
Mailing Address - Country:US
Mailing Address - Phone:912-996-4887
Mailing Address - Fax:
Practice Address - Street 1:7325 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-5006
Practice Address - Country:US
Practice Address - Phone:321-635-8564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL49261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist