Provider Demographics
NPI:1902606684
Name:RODRIGUEZ, ILEANA
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12581 SW LAGUNA REEF DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-6936
Mailing Address - Country:US
Mailing Address - Phone:201-674-0999
Mailing Address - Fax:
Practice Address - Street 1:1255 NE JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-7221
Practice Address - Country:US
Practice Address - Phone:772-225-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS24139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist