Provider Demographics
NPI:1306447065
Name:WYNTER, MALCOLM
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:WYNTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17650 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5019
Mailing Address - Country:US
Mailing Address - Phone:305-651-4636
Mailing Address - Fax:305-651-4862
Practice Address - Street 1:17650 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-5019
Practice Address - Country:US
Practice Address - Phone:305-651-4636
Practice Address - Fax:305-651-4862
Is Sole Proprietor?:No
Enumeration Date:2020-11-07
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist