Provider Demographics
NPI:1639998826
Name:MUDGE, CRISSIE (PHARMACIST)
Entity type:Individual
Prefix:
First Name:CRISSIE
Middle Name:
Last Name:MUDGE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 BURNT STORE RD S
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-1708
Mailing Address - Country:US
Mailing Address - Phone:239-690-4939
Mailing Address - Fax:
Practice Address - Street 1:611 BURNT STORE RD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-1708
Practice Address - Country:US
Practice Address - Phone:239-690-4939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL67764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist