Provider Demographics
NPI:1588934012
Name:ITANI, BASIL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BASIL
Middle Name:
Last Name:ITANI
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 1:2507 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-4612
Mailing Address - Country:US
Mailing Address - Phone:321-269-7772
Mailing Address - Fax:321-269-7718
Practice Address - Street 1:2507 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-4612
Practice Address - Country:US
Practice Address - Phone:321-269-7772
Practice Address - Fax:321-269-7718
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist