Basic Information
Provider Information | |||||||||
NPI: | 1366818080 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZELLERS | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2307 NE 16TH AVE | ||||||||
Address2: |   | ||||||||
City: | WILTON MANORS | ||||||||
State: | FL | ||||||||
PostalCode: | 333052405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2023217290 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 700 SE 3RD AVE FL 4 | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333161139 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9545223132 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2015 | ||||||||
LastUpdateDate: | 08/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH3314 | DC | N |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | PS47646 | FL | Y |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | RP044100L | PA | N |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | 0202208360 | VA | N |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.