Provider Demographics
NPI:1386429132
Name:THERVIL, KELSEIN (PHARMD)
Entity type:Individual
Prefix:
First Name:KELSEIN
Middle Name:
Last Name:THERVIL
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 1:3427 NW 37TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5456
Mailing Address - Country:US
Mailing Address - Phone:954-861-7854
Mailing Address - Fax:
Practice Address - Street 1:3101 NW 69TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1236
Practice Address - Country:US
Practice Address - Phone:954-861-7854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS66211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist