Provider Demographics
NPI:1700482791
Name:CHANEY, EUGENE RUTLEDGE IV
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:RUTLEDGE
Last Name:CHANEY
Suffix:IV
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 1:2201 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5319
Mailing Address - Country:US
Mailing Address - Phone:407-425-8623
Mailing Address - Fax:
Practice Address - Street 1:2201 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5319
Practice Address - Country:US
Practice Address - Phone:407-425-8623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28866333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy