Provider Demographics
NPI:1750035473
Name:HASEBROOCK, DAVID (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:HASEBROOCK
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 BLUE HIGHLANDS DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-2840
Mailing Address - Country:US
Mailing Address - Phone:813-203-4783
Mailing Address - Fax:
Practice Address - Street 1:2223 BLUE HIGHLANDS DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-2840
Practice Address - Country:US
Practice Address - Phone:813-203-4783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23133183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23133OtherFLORIDA DEPART OF HEALTH