Provider Demographics
NPI:1730469297
Name:FEDOROVICH, JOHN NICHOLAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:NICHOLAS
Last Name:FEDOROVICH
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 1:1829 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-1737
Mailing Address - Country:US
Mailing Address - Phone:386-672-6388
Mailing Address - Fax:386-672-0495
Practice Address - Street 1:1829 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-1737
Practice Address - Country:US
Practice Address - Phone:386-672-6388
Practice Address - Fax:386-672-0495
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS15388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist