Provider Demographics
NPI:1871831875
Name:BLACK, BRUCE STANLEY (R PH)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:STANLEY
Last Name:BLACK
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:MR
Other - First Name:BRUCE
Other - Middle Name:STANLEY
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:R PH
Mailing Address - Street 1:402 E DANIA BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-3040
Mailing Address - Country:US
Mailing Address - Phone:954-920-7660
Mailing Address - Fax:954-920-7660
Practice Address - Street 1:402 E DANIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:DANIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33004-3040
Practice Address - Country:US
Practice Address - Phone:954-920-7660
Practice Address - Fax:954-920-7660
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS13435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist