Provider Demographics
NPI:1891397238
Name:BOZARTH, BRENDA MAE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MAE
Last Name:BOZARTH
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 1:1300 JOHN SIMS PKWY E
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2208
Mailing Address - Country:US
Mailing Address - Phone:850-389-3124
Mailing Address - Fax:
Practice Address - Street 1:1300 JOHN SIMS PKWY E
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2208
Practice Address - Country:US
Practice Address - Phone:850-389-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15463183500000X
ALP16968183500000X
FLPS26143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist