Provider Demographics
NPI:1689708869
Name:CHAILITILERD, CHUKIAT (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHUKIAT
Middle Name:
Last Name:CHAILITILERD
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 1:1577 US HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-2150
Mailing Address - Country:US
Mailing Address - Phone:352-287-4920
Mailing Address - Fax:
Practice Address - Street 1:507 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-4311
Practice Address - Country:US
Practice Address - Phone:352-270-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS40657OtherDOH