Provider Demographics
NPI:1821648015
Name:TABLADA, JUSTINE TYRA MAE
Entity Type:Individual
Prefix:
First Name:JUSTINE TYRA MAE
Middle Name:
Last Name:TABLADA
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 1:1284 NW 159TH LN
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1629
Mailing Address - Country:US
Mailing Address - Phone:954-805-0592
Mailing Address - Fax:
Practice Address - Street 1:1601 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7344
Practice Address - Country:US
Practice Address - Phone:305-554-1706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist