Provider Demographics
NPI:1154794634
Name:MCKINNON, TA'SHAE (PHARMD)
Entity type:Individual
Prefix:
First Name:TA'SHAE
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 CROPPING ST
Mailing Address - Street 2:2209
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8722
Mailing Address - Country:US
Mailing Address - Phone:850-545-9543
Mailing Address - Fax:
Practice Address - Street 1:6401 CROPPING ST
Practice Address - Street 2:2209
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-8722
Practice Address - Country:US
Practice Address - Phone:850-545-9543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51399183500000X
FLPU7485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist