Provider Demographics
NPI:1184162257
Name:MOLINA BLANCO, ANDONI
Entity type:Individual
Prefix:
First Name:ANDONI
Middle Name:
Last Name:MOLINA BLANCO
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 1:14114 ALDFORD DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4777
Mailing Address - Country:US
Mailing Address - Phone:813-230-7363
Mailing Address - Fax:
Practice Address - Street 1:13801 LANDSTAR BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-5525
Practice Address - Country:US
Practice Address - Phone:407-723-4446
Practice Address - Fax:407-723-4436
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62048183500000X
FLPS55916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist