Provider Demographics
NPI:1356689673
Name:INGRAM, FANNIE A (RPH)
Entity type:Individual
Prefix:MRS
First Name:FANNIE
Middle Name:A
Last Name:INGRAM
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 1:5655 RED BUG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5013
Mailing Address - Country:US
Mailing Address - Phone:407-695-5814
Mailing Address - Fax:
Practice Address - Street 1:5655 RED BUG LAKE RD
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5013
Practice Address - Country:US
Practice Address - Phone:407-695-5814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL33406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist