Provider Demographics
NPI:1457892234
Name:FERNSTRUM, MICHAEL W
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:FERNSTRUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 E PARK DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-1337
Mailing Address - Country:US
Mailing Address - Phone:813-789-5920
Mailing Address - Fax:
Practice Address - Street 1:2655 GULF TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-4936
Practice Address - Country:US
Practice Address - Phone:727-373-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 32916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist