Provider Demographics
NPI:1134152101
Name:FORDE, ESAN N (PHARMD, CGP, MS)
Entity type:Individual
Prefix:DR
First Name:ESAN
Middle Name:N
Last Name:FORDE
Suffix:
Gender:M
Credentials:PHARMD, CGP, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 NW 179TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4450
Mailing Address - Country:US
Mailing Address - Phone:626-399-3021
Mailing Address - Fax:
Practice Address - Street 1:6321 NW 179TH TER
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4450
Practice Address - Country:US
Practice Address - Phone:626-399-3021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA571621835G0303X
FLPS43538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No183500000XPharmacy Service ProvidersPharmacist