Provider Demographics
NPI:1841913555
Name:MICOLUCCI, ANTHONY PAUL (RPH)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:PAUL
Last Name:MICOLUCCI
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 1:2818 MADRID ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6066
Mailing Address - Country:US
Mailing Address - Phone:904-945-0065
Mailing Address - Fax:
Practice Address - Street 1:2818 MADRID ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6066
Practice Address - Country:US
Practice Address - Phone:904-945-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty