Provider Demographics
NPI:1982209466
Name:AVILA, ANSEL
Entity Type:Individual
Prefix:
First Name:ANSEL
Middle Name:
Last Name:AVILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SENTOSA DR UNIT 207
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-9192
Mailing Address - Country:US
Mailing Address - Phone:714-876-8423
Mailing Address - Fax:
Practice Address - Street 1:5999 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-6265
Practice Address - Country:US
Practice Address - Phone:904-786-2148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist