Provider Demographics
NPI:1831794197
Name:MOBERG, DEVIN
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:
Last Name:MOBERG
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 1:6060 JESSICA DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-1957
Mailing Address - Country:US
Mailing Address - Phone:772-979-2261
Mailing Address - Fax:
Practice Address - Street 1:24450 SR 44
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32736
Practice Address - Country:US
Practice Address - Phone:352-357-2576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist