Provider Demographics
NPI:1851992424
Name:KNUDSTRUP, MICHAEL C (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:KNUDSTRUP
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95084 SPRING TIDE LN
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-5460
Mailing Address - Country:US
Mailing Address - Phone:904-349-0167
Mailing Address - Fax:
Practice Address - Street 1:1385 AMELIA PLZ
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1998
Practice Address - Country:US
Practice Address - Phone:904-261-5522
Practice Address - Fax:904-321-1947
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS17578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist