Provider Demographics
NPI:1902448798
Name:WAITE, ALBERT GORTON JR
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:GORTON
Last Name:WAITE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 BALMY BEACH DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-5937
Mailing Address - Country:US
Mailing Address - Phone:407-457-6293
Mailing Address - Fax:
Practice Address - Street 1:820 BALMY BEACH DR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-5937
Practice Address - Country:US
Practice Address - Phone:407-457-6293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-13
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist