Provider Demographics
NPI:1134795222
Name:HARRIS, JACK KIRSCHENFELD
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:KIRSCHENFELD
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACKSON
Other - Middle Name:KIRSCHENFELD
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 INTERNATIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7302
Mailing Address - Country:US
Mailing Address - Phone:407-333-3104
Mailing Address - Fax:
Practice Address - Street 1:100 INTERNATIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-7302
Practice Address - Country:US
Practice Address - Phone:407-333-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist