Provider Demographics
NPI:1336434927
Name:MCCLINTOCK, THERESA (PHARMD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MCCLINTOCK
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 1:11406 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7963
Mailing Address - Country:US
Mailing Address - Phone:904-262-5991
Mailing Address - Fax:904-262-5991
Practice Address - Street 1:10490 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6207
Practice Address - Country:US
Practice Address - Phone:904-268-3995
Practice Address - Fax:904-268-3995
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS32926183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist