Provider Demographics
NPI:1760823306
Name:LAND, JOHN C III
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LAND
Suffix:III
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 1:9828 NEW PARKE RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-5127
Mailing Address - Country:US
Mailing Address - Phone:239-560-8125
Mailing Address - Fax:
Practice Address - Street 1:4651 W KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2519
Practice Address - Country:US
Practice Address - Phone:813-286-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS53515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist