Provider Demographics
NPI:1639725989
Name:MESADIEU, MARC CHARLES
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:CHARLES
Last Name:MESADIEU
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 1:9048 BONITA BEACH RD SE
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9048 BONITA BEACH RD SE
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4237
Practice Address - Country:US
Practice Address - Phone:239-221-7233
Practice Address - Fax:185-576-5770
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist