Provider Demographics
NPI:1659929503
Name:GREENWALD, MARK (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GREENWALD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16097 AVON PARK CUT OFF RD
Mailing Address - Street 2:
Mailing Address - City:FORT MEADE
Mailing Address - State:FL
Mailing Address - Zip Code:33841-9287
Mailing Address - Country:US
Mailing Address - Phone:863-257-0684
Mailing Address - Fax:
Practice Address - Street 1:805 HAVENDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-1311
Practice Address - Country:US
Practice Address - Phone:863-293-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist