Provider Demographics
NPI:1245701879
Name:WHITEHEAD, MIA
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11137 LEM TURNER ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218
Mailing Address - Country:US
Mailing Address - Phone:904-859-7043
Mailing Address - Fax:
Practice Address - Street 1:6132 MERRILL RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-3459
Practice Address - Country:US
Practice Address - Phone:904-683-7059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL58413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL58413OtherPHARMACIST