Provider Demographics
NPI:1649755059
Name:GRONDONA CONSUEGRA, IVAN JOSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:JOSE
Last Name:GRONDONA CONSUEGRA
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 1:3049 AZALEA LN
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-8313
Mailing Address - Country:US
Mailing Address - Phone:863-840-3125
Mailing Address - Fax:
Practice Address - Street 1:5 US 27 S
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7916
Practice Address - Country:US
Practice Address - Phone:863-465-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist