Provider Demographics
NPI:1902191612
Name:TIBBITTS, LEE PAUL JR (RPH)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:PAUL
Last Name:TIBBITTS
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CROCKETT BLVD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4395
Mailing Address - Country:US
Mailing Address - Phone:321-452-1691
Mailing Address - Fax:321-452-1691
Practice Address - Street 1:250 CROCKETT BLVD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4395
Practice Address - Country:US
Practice Address - Phone:321-452-1691
Practice Address - Fax:321-452-1691
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0028651183500000X
MA18651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist