Provider Demographics
NPI:1932718715
Name:VERSULIEN, LUKESON GIDEON
Entity Type:Individual
Prefix:
First Name:LUKESON
Middle Name:GIDEON
Last Name:VERSULIEN
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 1:9700 ARGYLE FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-2809
Mailing Address - Country:US
Mailing Address - Phone:904-778-0871
Mailing Address - Fax:904-778-9493
Practice Address - Street 1:9700 ARGYLE FOREST BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-2809
Practice Address - Country:US
Practice Address - Phone:904-778-0871
Practice Address - Fax:904-778-9493
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS60853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1497760680OtherNPI