Provider Demographics
NPI:1942803663
Name:FASUL, KATINA
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:
Last Name:FASUL
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 1:141 E WOOLBRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-6007
Mailing Address - Country:US
Mailing Address - Phone:561-736-1010
Mailing Address - Fax:
Practice Address - Street 1:141 E WOOLBRIGHT RD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-6007
Practice Address - Country:US
Practice Address - Phone:561-736-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS26760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist