Provider Demographics
NPI:1295289841
Name:ATLIVANAU, ANDREI V (PHARMD)
Entity type:Individual
Prefix:
First Name:ANDREI
Middle Name:V
Last Name:ATLIVANAU
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 N MCMULLEN BOOTH RD
Mailing Address - Street 2:SUITE F3-121
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2510
Mailing Address - Country:US
Mailing Address - Phone:305-469-0866
Mailing Address - Fax:
Practice Address - Street 1:12550 PROFESSIONAL PARK DR
Practice Address - Street 2:#1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-7979
Practice Address - Country:US
Practice Address - Phone:305-469-0866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55335183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist