Provider Demographics
NPI:1932514940
Name:TAVERAS, LUIS J (PS)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:J
Last Name:TAVERAS
Suffix:
Gender:M
Credentials:PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N FERNCREEK AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4108
Mailing Address - Country:US
Mailing Address - Phone:407-440-4504
Mailing Address - Fax:407-674-7935
Practice Address - Street 1:715 N FERNCREEK AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4108
Practice Address - Country:US
Practice Address - Phone:407-440-4504
Practice Address - Fax:407-674-7935
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS13139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist