Provider Demographics
NPI:1710229869
Name:BETANCOURT, ICEL (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:ICEL
Middle Name:
Last Name:BETANCOURT
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 1:870 NW 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3129
Mailing Address - Country:US
Mailing Address - Phone:305-608-5875
Mailing Address - Fax:
Practice Address - Street 1:870 NW 106TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-3129
Practice Address - Country:US
Practice Address - Phone:305-608-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPU5530183500000X
FLPS358821835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist