Provider Demographics
NPI:1962749143
Name:GILLIS, JOHN F
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:GILLIS
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 1:19390 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3041
Mailing Address - Country:US
Mailing Address - Phone:352-796-2928
Mailing Address - Fax:352-796-2929
Practice Address - Street 1:19390 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3041
Practice Address - Country:US
Practice Address - Phone:352-796-2928
Practice Address - Fax:352-796-2929
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20020183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist