Provider Demographics
NPI:1265903785
Name:BETANCOURT, XAVIER (PHARMD)
Entity type:Individual
Prefix:
First Name:XAVIER
Middle Name:
Last Name:BETANCOURT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2754 NAVEL DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2311
Mailing Address - Country:US
Mailing Address - Phone:727-458-5126
Mailing Address - Fax:
Practice Address - Street 1:12024 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-5682
Practice Address - Country:US
Practice Address - Phone:813-264-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS58607OtherFLORIDA BOARD OF PHARMACY