Provider Demographics
NPI:1891033056
Name:TELLEZ, ROBERTO A (PHARM D)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:A
Last Name:TELLEZ
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1566 BELLA CRUZ DR
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8969
Mailing Address - Country:US
Mailing Address - Phone:352-750-9863
Mailing Address - Fax:
Practice Address - Street 1:1566 BELLA CRUZ DR
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8969
Practice Address - Country:US
Practice Address - Phone:352-750-9863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist