Provider Demographics
NPI:1821652959
Name:SOTO-OMAR, PEGGY
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:SOTO-OMAR
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 1:10371 HENBURY ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-6954
Mailing Address - Country:US
Mailing Address - Phone:407-492-3041
Mailing Address - Fax:
Practice Address - Street 1:3990 E SR 44 UNIT 207
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-7482
Practice Address - Country:US
Practice Address - Phone:352-492-9333
Practice Address - Fax:352-399-6234
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH31701333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy