Provider Demographics
NPI:1316516222
Name:LIWANAG, JANSEN MENDOZA (RPH)
Entity type:Individual
Prefix:
First Name:JANSEN
Middle Name:MENDOZA
Last Name:LIWANAG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2030
Mailing Address - Country:US
Mailing Address - Phone:407-617-2399
Mailing Address - Fax:
Practice Address - Street 1:115 E STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5273
Practice Address - Country:US
Practice Address - Phone:407-830-7350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL62183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist