Provider Demographics
NPI:1285914762
Name:FIALLO, DANIEL R (PHARMD)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:R
Last Name:FIALLO
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 1:11430 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-3806
Mailing Address - Country:US
Mailing Address - Phone:904-641-1581
Mailing Address - Fax:904-641-2839
Practice Address - Street 1:11430 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-3806
Practice Address - Country:US
Practice Address - Phone:904-641-1581
Practice Address - Fax:904-641-2839
Is Sole Proprietor?:No
Enumeration Date:2011-08-28
Last Update Date:2011-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist