Provider Demographics
NPI:1992846539
Name:FLORIDA DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:LEE COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-461-6148
Mailing Address - Street 1:83 PONDELLA RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-4411
Mailing Address - Country:US
Mailing Address - Phone:239-461-6148
Mailing Address - Fax:239-461-6160
Practice Address - Street 1:83 PONDELLA RD
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-4411
Practice Address - Country:US
Practice Address - Phone:239-461-6148
Practice Address - Fax:239-461-6160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH106943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1068154OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL027946316Medicaid
FL027946309Medicaid