Provider Demographics
NPI:1770852279
Name:BACCHUS, AMEENA (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMEENA
Middle Name:
Last Name:BACCHUS
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 1:15507 STONEYBROOK WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787
Mailing Address - Country:US
Mailing Address - Phone:407-905-4044
Mailing Address - Fax:407-905-4047
Practice Address - Street 1:15507 STONEYBROOK WEST PKWY
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4734
Practice Address - Country:US
Practice Address - Phone:407-905-4044
Practice Address - Fax:407-905-4047
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist