Provider Demographics
NPI:1881126522
Name:ELIOGU, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:ELIOGU
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 1:1333 W C 48
Mailing Address - Street 2:SUITE A
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-8923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1333 W C 48
Practice Address - Street 2:SUITE A
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-8923
Practice Address - Country:US
Practice Address - Phone:352-793-2679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019905200Medicaid