Provider Demographics
NPI:1417189291
Name:FASNACHT, DOUGLAS (PHARMD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:FASNACHT
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 1:22920 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-6931
Mailing Address - Country:US
Mailing Address - Phone:813-949-7872
Mailing Address - Fax:813-949-6690
Practice Address - Street 1:22920 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6931
Practice Address - Country:US
Practice Address - Phone:813-949-7872
Practice Address - Fax:813-949-6690
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL39620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist