Provider Demographics
NPI:1063055044
Name:VAN CLEAVE, PURITA
Entity type:Individual
Prefix:
First Name:PURITA
Middle Name:
Last Name:VAN CLEAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11114 COPPERLEFE DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-2406
Mailing Address - Country:US
Mailing Address - Phone:941-238-8579
Mailing Address - Fax:
Practice Address - Street 1:4536 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4112
Practice Address - Country:US
Practice Address - Phone:941-213-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57048183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017095200Medicaid