Provider Demographics
NPI:1013281328
Name:TITA-BAKARE, SUSAN
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:TITA-BAKARE
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 1:701 WEST DR M.L.K. JR BLVD
Mailing Address - Street 2:SUITE1
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603
Mailing Address - Country:US
Mailing Address - Phone:813-335-0267
Mailing Address - Fax:813-849-0992
Practice Address - Street 1:701 WEST DR M,L.K. JR BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603
Practice Address - Country:US
Practice Address - Phone:813-335-0267
Practice Address - Fax:813-849-0992
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS30107OtherSTATE LICENCE NUMBER