Provider Demographics
NPI:1164011862
Name:RADVIL, AUDRA LINA
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:LINA
Last Name:RADVIL
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 1:4685 GULF BLVD
Mailing Address - Street 2:
Mailing Address - City:ST PETE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33706-2405
Mailing Address - Country:US
Mailing Address - Phone:727-360-0818
Mailing Address - Fax:727-367-1049
Practice Address - Street 1:4685 GULF BLVD
Practice Address - Street 2:
Practice Address - City:ST PETE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33706-2405
Practice Address - Country:US
Practice Address - Phone:727-360-0818
Practice Address - Fax:727-367-1049
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT17451183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician