Provider Demographics
NPI:1992350409
Name:SELFRIDGE, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:SELFRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 BEVILLE RD #300
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117
Mailing Address - Country:US
Mailing Address - Phone:904-455-4226
Mailing Address - Fax:
Practice Address - Street 1:1500 BEVILLE RD #300
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:904-455-4226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59598183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist