Provider Demographics
NPI:1629404066
Name:MUCKERHEIDE, CARL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:MUCKERHEIDE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 ALBEE RD W
Mailing Address - Street 2:APT 5
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-2539
Mailing Address - Country:US
Mailing Address - Phone:401-662-7933
Mailing Address - Fax:
Practice Address - Street 1:1445 E VENICE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-3064
Practice Address - Country:US
Practice Address - Phone:941-480-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist