Provider Demographics
NPI:1245511286
Name:PROVAN, SPENCER (RPH)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:PROVAN
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 1:1208 DRISCOLL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-9647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1208 DRISCOLL DR
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-9647
Practice Address - Country:US
Practice Address - Phone:863-385-9929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS17671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist