Provider Demographics
NPI:1679810329
Name:FITZGERALD, JOHN M (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:FITZGERALD
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 1:1700 SW MOCKINGBIRD DR.
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986
Mailing Address - Country:US
Mailing Address - Phone:772-284-8988
Mailing Address - Fax:
Practice Address - Street 1:5473 NE ST JAMES DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983
Practice Address - Country:US
Practice Address - Phone:772-878-1526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist