Provider Demographics
NPI:1184152886
Name:DIAMOND, JACK (RPH)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DIAMOND
Suffix:
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 1:27356 GOLF COURSE LOOP
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-3703
Mailing Address - Country:US
Mailing Address - Phone:813-973-7035
Mailing Address - Fax:
Practice Address - Street 1:27225 STATE ROAD 56
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-8832
Practice Address - Country:US
Practice Address - Phone:813-973-7035
Practice Address - Fax:813-973-7396
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS24807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016460200Medicaid