Provider Demographics
NPI:1790051415
Name:DAHL, MARK KENNETH (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:KENNETH
Last Name:DAHL
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 1:930 MALABAR RD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3252
Mailing Address - Country:US
Mailing Address - Phone:321-775-0911
Mailing Address - Fax:321-775-0912
Practice Address - Street 1:930 MALABAR RD SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3252
Practice Address - Country:US
Practice Address - Phone:321-775-0911
Practice Address - Fax:321-775-0912
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS15899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist