Provider Demographics
NPI:1386233476
Name:MBALLESUBE, BERNARD (PHARMD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:MBALLESUBE
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 1:5151 BELLE TERRE PKWY
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8689
Mailing Address - Country:US
Mailing Address - Phone:386-446-9449
Mailing Address - Fax:386-446-9971
Practice Address - Street 1:5151 BELLE TERRE PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8689
Practice Address - Country:US
Practice Address - Phone:386-446-9449
Practice Address - Fax:386-446-9971
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS408733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy