Provider Demographics
NPI:1710089669
Name:FUTCH, JACQUELINE ANNE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANNE
Last Name:FUTCH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12500 OLD GRADE RD
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33868-9595
Mailing Address - Country:US
Mailing Address - Phone:863-984-4723
Mailing Address - Fax:863-984-9631
Practice Address - Street 1:108 N COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:FL
Practice Address - Zip Code:33868
Practice Address - Country:US
Practice Address - Phone:863-984-3427
Practice Address - Fax:863-984-9631
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA37625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist