Provider Demographics
NPI:1750008504
Name:MUFORO, MARTIN U (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:U
Last Name:MUFORO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PATRIOT LN APT 228
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-7404
Mailing Address - Country:US
Mailing Address - Phone:813-340-1098
Mailing Address - Fax:
Practice Address - Street 1:748 BEAL PKWY NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-3002
Practice Address - Country:US
Practice Address - Phone:850-863-2204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS64901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS64901Medicaid