Provider Demographics
NPI:1205117694
Name:PENDERGRASS, SHARON S (RPH)
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:S
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 S NOVA RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4201
Mailing Address - Country:US
Mailing Address - Phone:386-756-0776
Mailing Address - Fax:386-760-3827
Practice Address - Street 1:3805 S NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4201
Practice Address - Country:US
Practice Address - Phone:386-756-0776
Practice Address - Fax:386-760-3827
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS20802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist