Provider Demographics
NPI:1538379813
Name:FEDELES, RONALD ALLEN (RPH, NPH, LMT)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:ALLEN
Last Name:FEDELES
Suffix:
Gender:M
Credentials:RPH, NPH, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11403 N GRADY AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-8745
Mailing Address - Country:US
Mailing Address - Phone:813-960-7244
Mailing Address - Fax:
Practice Address - Street 1:2901 W BUSCH BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4523
Practice Address - Country:US
Practice Address - Phone:813-931-8700
Practice Address - Fax:813-931-8755
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 17352183500000X
FLNP 871835N0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835N0905XPharmacy Service ProvidersPharmacistNuclear