Provider Demographics
NPI:1942578018
Name:NASRALLA, MICKEL (RPH)
Entity Type:Individual
Prefix:
First Name:MICKEL
Middle Name:
Last Name:NASRALLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7245 WINDING LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5664
Mailing Address - Country:US
Mailing Address - Phone:321-720-2094
Mailing Address - Fax:
Practice Address - Street 1:820 OVIEDO MARKETPLACE BLVD
Practice Address - Street 2:TARGET PHARMACY
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9305
Practice Address - Country:US
Practice Address - Phone:407-366-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS44864OtherFL BOARD OF PHARMACY LICENSE NUMBER