Provider Demographics
NPI:1972870327
Name:VIDAL, FERMIN O
Entity type:Individual
Prefix:MR
First Name:FERMIN
Middle Name:O
Last Name:VIDAL
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:FERMIN
Other - Middle Name:O
Other - Last Name:VIDAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:423 NW 101ST ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1388
Mailing Address - Country:US
Mailing Address - Phone:352-322-1637
Mailing Address - Fax:
Practice Address - Street 1:807 E SILVER SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-6709
Practice Address - Country:US
Practice Address - Phone:352-629-8721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0023561183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0023561OtherSTATE LICENCE NUMBER