Provider Demographics
NPI:1699045096
Name:WACKERLY, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:WACKERLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 BACKSTAGE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE BUENA VISTA
Mailing Address - State:FL
Mailing Address - Zip Code:32830
Mailing Address - Country:US
Mailing Address - Phone:407-934-2030
Mailing Address - Fax:407-934-2031
Practice Address - Street 1:960 BACKSTAGE LN
Practice Address - Street 2:
Practice Address - City:LAKE BUENA VISTA
Practice Address - State:FL
Practice Address - Zip Code:32830
Practice Address - Country:US
Practice Address - Phone:407-934-2030
Practice Address - Fax:407-934-2031
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS35907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist