Provider Demographics
NPI:1710603998
Name:BAE, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BAE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 ROSELING CIR UNIT 228
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5195
Mailing Address - Country:US
Mailing Address - Phone:520-390-1921
Mailing Address - Fax:
Practice Address - Street 1:5280 S JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-5026
Practice Address - Country:US
Practice Address - Phone:520-390-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS65018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist