Provider Demographics
NPI:1104110576
Name:MANSOUR, JOHN (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301143
Mailing Address - Street 2:
Mailing Address - City:FERN PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32730-1143
Mailing Address - Country:US
Mailing Address - Phone:407-490-8682
Mailing Address - Fax:
Practice Address - Street 1:1314 S BAY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5551
Practice Address - Country:US
Practice Address - Phone:352-357-6699
Practice Address - Fax:352-357-2390
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist