Provider Demographics
NPI:1790328581
Name:CASTILLO, JANNISE
Entity Type:Individual
Prefix:
First Name:JANNISE
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10635 W ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-5669
Mailing Address - Country:US
Mailing Address - Phone:954-345-9250
Mailing Address - Fax:954-345-9248
Practice Address - Street 1:10635 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-5669
Practice Address - Country:US
Practice Address - Phone:954-345-9250
Practice Address - Fax:954-345-9248
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58174333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy