Provider Demographics
NPI:1194001008
Name:MEDINA, MARK (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MEDINA
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 1:8951 HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-8030
Mailing Address - Country:US
Mailing Address - Phone:727-869-7224
Mailing Address - Fax:
Practice Address - Street 1:8951 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-8030
Practice Address - Country:US
Practice Address - Phone:727-869-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46456183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist