Provider Demographics
NPI:1972096063
Name:FORD, JOHN EDWIN JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWIN
Last Name:FORD
Suffix:JR
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 1:11300 LINDBERGH BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8827
Mailing Address - Country:US
Mailing Address - Phone:866-249-2696
Mailing Address - Fax:
Practice Address - Street 1:11300 LINDBERGH BLVD STE 107
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8827
Practice Address - Country:US
Practice Address - Phone:866-249-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist