Provider Demographics
NPI:1962757278
Name:MERRILL, JESSICA ALYCE (PHARMD)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ALYCE
Last Name:MERRILL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17450 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6748
Mailing Address - Country:US
Mailing Address - Phone:352-385-0516
Mailing Address - Fax:
Practice Address - Street 1:17450 US HIGHWAY 441
Practice Address - Street 2:T-2062
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6748
Practice Address - Country:US
Practice Address - Phone:352-385-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist