Provider Demographics
NPI:1245850379
Name:TZIVANIS, MAGGIE
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:
Last Name:TZIVANIS
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 1:4424 MAIN ST APT 4055
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1954 SW GATLIN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2722
Practice Address - Country:US
Practice Address - Phone:772-224-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-18
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist