Provider Demographics
NPI:1720315674
Name:NORIEGA, JOHN BASIL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BASIL
Last Name:NORIEGA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-1863
Mailing Address - Country:US
Mailing Address - Phone:813-629-4654
Mailing Address - Fax:
Practice Address - Street 1:202 E BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5221
Practice Address - Country:US
Practice Address - Phone:813-689-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist