Provider Demographics
NPI:1487721890
Name:STATEN, DOUGLAS WYNN (RPH)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WYNN
Last Name:STATEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4829
Mailing Address - Country:US
Mailing Address - Phone:404-218-9704
Mailing Address - Fax:386-236-9341
Practice Address - Street 1:3422 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH SHORES
Practice Address - State:FL
Practice Address - Zip Code:32118-6349
Practice Address - Country:US
Practice Address - Phone:386-756-0481
Practice Address - Fax:386-756-0498
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08338183500000X
FLPS44814183500000X
GARPH021909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist