Provider Demographics
NPI:1659972263
Name:KING, MARK L (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:KING
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15495 PANAMA CITY BEACH PKWY
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-5409
Mailing Address - Country:US
Mailing Address - Phone:850-708-6971
Mailing Address - Fax:850-708-6972
Practice Address - Street 1:15495 PANAMA CITY BEACH PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-5409
Practice Address - Country:US
Practice Address - Phone:850-708-6971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL42836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00834340Medicaid